Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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Chairman, Research Group, Charutar Arogya Mandal, Karamsad
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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Dr. Saumya Navit

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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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C.S. Ramesh Babu,
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Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : RC01 - RC04 Full Version

Intramedullary Nail Supplemented with Poller Screws for Proximal and Distal 1/3rd Shaft Tibial Fracture: A Prospective Interventional Study from North India


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57214.17202
Girish Sahni, Harish Bansal, Ashish Garg, Akashdeep Singh, Ashish Kavia, Hari Om Aggarwal

1. Professor, Department of Orthopaedics, Government Medical College, Patiala, Punjab, India. 2. Junior Resident, Department of Orthopaedics, Government Medical College, Patiala, Punjab, India. 3. Senior Resident, Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India. 4. Senior Resident, Department of Orthopaedics, Government Medical College, Patiala, Punjab, India. 5. Assistant Professor, Department of Physical Medicine and Rehabilitation, Government Medical College, Patiala, Punjab, India. 6. Professor, Department of Orthopaedics, Government Medical College, Patiala, Punjab, India.

Correspondence Address :
Dr. Hari Om Aggarwal,
H. No. 34, Dhaliwal Colony, Patiala, Punjab, India.
E-mail: drhariom62@gmail.com

Abstract

Introduction: The fracture of shaft of the tibia is the most common long bone fracture. The treatment goal for shaft tibial fracture is to achieve union with correction of both axial and rotational alignment and, maintain initial fracture length. Higher malunion rates are seen in fractures of the proximal and distal 1/3rd of the shaft of the tibia. However, Intramedullary (IM) nailing is the preferred choice of operative management of diaphyseal fractures of the lower limb.

Aim: To evaluate the functional and radiological outcomes of IM nail supplemented with Poller screws for proximal and distal 1/3rd shaft tibial fractures.

Materials and Methods: A prospective, interventional study was conducted in the Government Medical College, Patiala, Punjab, India from May 2020 to November 2021. A total of 30 fracture patients in the age group of 18 to 60 years were included in the study. All the subjects were treated with IM nail supplemented with Poller screws for proximal and distal 1/3rd shaft tibial fractures. Twenty cases were closed fractures and 10 were open (grade I or II according to Gustilo Anderson’s classification of compound tibia fracture). Patients were followed-up at 3 weeks, then 6 weekly till union. Patients were evaluated by Karlstro¨m-Olerud’s functional evaluation criteria.The data was statistically analysed using IBM Statistical Package for the Social Sciences (SPSS) software version 23.0.

Results: The mean time of fracture union was 17.33±2.59 weeks with a maximum (n=19) patients in ≤15 weeks, followed by 15-20 weeks (n=10) and only one patient had delayed union (>20 weeks). According to Karlström-Olerud’s functional evaluation scale 18 (60%) patients had excellent outcome followed by good outcome in 8 (26.7%) patients, while 2 (6.7%) patients had satisfactory and 2 (6.7%) patients moderate outcomes. The total mean varus/valgus deformity preoperatively was 10.17±4.15° while postoperatively it was 1.63±2.3°. The total mean antecurvatum/recurvatum deformity preoperatively was 6.47±5.906° while postoperatively it was 0.20±0.61°. Postoperative complications were observed such as shortening of the leg (n=2), movement loss in the ankle (n=4), movement loss in the knees (n=3), muscle wasting (n=6) and subtalar movement loss (n=6). One patient had a superficial skin infection (oozing of purulent discharge from distal locking skin suture site), which was treated with prolonged antibiotics.

Conclusion: Poller screws were found to be effective in achieving fracture alignment and hence, serve as a effective fracture reduction tool. Also helps to maintain the fracture aligned until it healed, preventing the loss of the initial reduction.

Keywords

Antecurvatum, Gustilo anderson classification, Karlström-olerud’s functional evaluation scale, Recurvatum

The fracture of shaft of the tibia is the most common fracture and is seen in nearly 4% of the old population. Both low and high energy mechanisms are involved in causing these fractures (1). The aim of the treatment for the shaft of tibia fracture is to achieve union with correction of both axial and rotational alignment and to maintain initial fracture length. Early mobilisation of the patient along with pain free weight bearing and functional range of movement of the knee and ankle joints are also advocated (2),(3),(4),(5). Proximal tibia fractures are defined as, those extending from the articular surface up to 1.5 times, the medial to the lateral width of the articular surface, and most commonly occur due to high velocity trauma. Operative management is preferred, as in conservative management, there is a risk of malunion, non union or joint stiffness. Fractures of the proximal and distal one-thirds of the tibial shaft have remained a challenge and higher malunion rates were observed (6).

Non articular fractures of the proximal third of the tibia account for 5-11% of tibial shaft injuries (1). These fractures frequently, result in malunion with apex anterior and valgus deformities. Similarly, displaced extra-articular fractures of the distal tibia are difficult to treat, with residual varus, valgus, recurvatum, or procurvatum. The small size of the distal fragment can make both, maintaining the reduction and placing adequate distal locking fixation difficult, with the centre-centre placement of the nail in both the proximal and distal fragments being critical (1).

The goals of surgical management include correction, and maintenance of sagittal and coronal alignment, the establishment of length and rotation, and early functional range of movements of the knee and ankle. However, Intramedullary (IM) nailing is the preferred choice for operative management of diaphyseal fractures of the lower limb and is also a part of the armamentarium for the treatment of metaphyseal fractures. Nailing of metaphyseal fractures with a short distal fragment is associated with an increase in malalignment particularly in the coronal plane, non union, and the need for secondary procedures to achieve union. There are limitations with the ‘standard’ practice of IM nailing in the treatment of metaphyseal fractures, owing to the long lever arm, metaphyseal enlargement, and epiphyseal-metaphyseal fixation problems, which make the reduction and controlling angulation of the shorter bone fragment technically difficult. This may be attributed to an inaccurate entry site or both displacing muscular forces and residual instability (7).

To improve the fixation of the nail, in metaphyseal fractures various techniques have been recommended; including percutaneous reduction clamps, fibular plating, temporary unicortical plating, and blocking screws (Poller screw).

To prevent axial deformities in proximal or distal third tibia fractures during IM nailing, the “Poller screw” was firstly described by Krettek in 1999, which was similar to the metal devices designed to block or guide traffic. The Poller screw acts by reduction of the width of the medullary canal in the metaphyseal area and thus, by providing a tight fitting for the intramedullary nail. Therefore, it increases the stability of the bone-implant construct (7),(8),(9). A high degree of axial malalignment was seen in the proximal and distal third tibial shaft fracture of the metaphyseal region, which was stabilised with locking intramedullary nails along with Poller screws. The cause of this was muscular forces which displace the fracture and causes instability (10). As there is a paucity of articles comparing the clinical usefulness of Poller screw augmentation against that of IM nail alone for the treatment of long bone fractures. Therefore, the aim of the present study was to evaluate the outcome of IM nailing supplemented with Poller screws for proximal and distal 1/3rd shaft tibial fractures.

Material and Methods

The present prospective, interventional study was conducted in the Department of Orthopaedics, Rajindra Hospital, Government Medical College, Patiala, Punjab, India from May 2020 to November 2021 after taking the ethical clearance from Institutional Research Ethics Committee vide letter number (317\2020). Informed consent was obtained from the study participants.

A total of 20 males and 10 females (total 30 fractures) in the age group between 18 to 60 years, who had undergone IM nailing with Poller screws augmentation for proximal and distal 1/3rd shaft tibial fractures form the sample population. Most (n=20) of the patients had closed fractures and 10 patients had open fractures.

Inclusion criteria: Patients between age group between 18 to 60 years who have closed fractures of both bone legs or have open fractures in proximal 1/3rd and distal 1/3rd shaft tibia according to Gustilo Anderson classification 2 (1) were included in the study.

Exclusion criteria: Patients with the proximal tibial fractured fragment, less than 7 cm, with proximal and distal tibial intra-articular fracture line, within displaced fractures were excluded. Patients with any haematological disorder like thrombocytopenia and patients with open fractures of both bone leg according to Gustilo Anderson classification 3A, 3B and 3C and extensively comminuted fractures were excluded from the study.

Study Procedure

Intraoperatively, on a well-padded knee rest, the knee was kept in a semi-extended position. Poller screw was fixed on the opposite side to the apex of deformity, along the concave border in both Anteroposterior (AP) and lateral views under fluoroscopic guidance. After patellar tendon retraction at midline, by bone awl; a high entry point was made. The guided wire was passed to the centre, position was checked fluoroscopically on AP and lateral views, then sequential reaming was done. Reamed nail of appropriate length and diameter was inserted slowly while negotiating with the Poller screws. Locking of the nail was done both proximally and distally. Poller screws were retained (Table/Fig 1).

Postoperatively, patients were mobilised on postoperative day one of surgery. Physical therapy in the form of static and dynamic quadriceps exercises were given. For six to eight weeks partial weight-bearing (15 to 20 kg) was allowed. Then, weight-bearing was increased, depending on the radiographic evidence of bone union and the absence of pain. The first follow-up was done on 21st day, then each follow-up was done for every six weeks until the union was achieved. Patients were evaluated by Karlström-Olerud’s functional evaluation criteria (Table/Fig 2) (11),(12).

Points were given and added up based on the above criteria as below scores:

36 points: excellent
35-33 points: good
32-30 points: satisfactory
29-27 points: moderate
26-24 points: poor

Alignment and deformity were calculated from postoperative X-ray and the degree of varus/valgus, and antecurvatum/recurvatum malalignment were then calculated. Varus and antecurvatum angulation were symbolised as positive (+) values. Valgus and recurvatum were symbolised as negative (-) values.

Statistical Analysis

The data was entered in the form of a data matrix in Microsoft Excel® and statistically analysed using IBM Statistical Package for the Social Sciences (SPSS) software version 23.0. Paired t-test were used for comparing mean values.

Results

Male predominance was observed in this study with 20 (66.7%) males and 10 (33.3%) females. It was observed that 40% of patients were in the age group 41-50 years. The mean age of the patients was 39.36±9.9 years (Table/Fig 3).

In all the patients, the closed reduction technique was done. Among 30 cases, 18 cases needed one additional Poller screw to correct the existing deformity. The mean time for fracture union was 17.33±2.59 weeks with 19 patients presenting in between range ≤15 weeks, followed by 10 patients in 16-20 weeks and only one patient had delayed union >20 weeks. About 60% of patients (n=18) in the present study had excellent outcomes, followed by good outcome was seen in 8 (26.7%) patients, 2 (6.7%) patients each had satisfactory and moderate outcome according to KARLSTRÖM-OLERUD’S FUNCTIONAL EVALUATION.

Residual mean varus alignment postoperatively was +1.47° when compared to the preoperative mean value of +9.06°. Residual mean valgus malalignment postoperatively was -1.85° when compared to the preoperative mean value of -11.62° (Table/Fig 4).

The total mean varus/valgus deformity preoperatively was 10.17±4.15° while postoperatively it was 1.63±2.3°. Statistically, a significant difference was observed between the two (p-value <0.05) (Table/Fig 5). In the present study, five patients had varus and valgus >5°, and 25 patients had <5° after surgery.

Postoperative mean antecurvatum angulation was +0.12° when compared to the preoperative mean value of +5.71°. Postoperative mean recurvatum angulation was -0.31° when compared to the preoperative mean value of -7.77° (Table/Fig 6).

The total mean antecurvatum/recurvatum deformity preoperatively was 6.47±5.9°, while postoperatively it was 0.20±.61° (Table/Fig 7).

Postoperative complications included shortening of the leg, two patients had 0.5 cm shortening, four patients had 10° loss in ankle dorsiflexion and three patients lost movement in knees (two patients with 20° Flexion and one with 15° flexion loss, and six patients there was subtalar movement loss (two patients with 10° inversion loss, three patients with 5° inversion loss, and one patient with 5° eversion loss) and one patient had oozing of purulent discharge from distal locking skin suture site, which was treated with washing and prolonged antibiotics (Table/Fig 8).

Discussion

Male predominance was observed in the present study with 66.7% males and 33.3% females. The mean age of the patients in the present study was 39.36±9.9 years. In a study by Kulkarni SG et al., also male predominance was observed with 71.4% of patients being male (13). Kumar A et al., 2020 showed M:F ratioto be 83.3%, with males to be five times more than females (14). Hussain T et al., in 2020 showed 57.1% of patients with tibial shaft fractures to be male (15).

Most of the patients i.e. 66.7% had closed fractures. Kumar A et al., in their study showed the prevalence of grade I and II fractures (14). A total of 10 ten patients were in grade I and II combined in the present study. In this study, 17 cases were of valgus while 13 were varus. The range of varus to valgus malalignment varies from +14 to -20° preoperatively and it changed to +8 to -7° postoperatively with only five (16.6%)cases having >5° postoperatively. In a study by Kulkarni SG et al., preoperatively, of the total 75 cases, 30 were varus, 10 were neutraland 35 were valgus (13). The range of varus to valgus varies from +24 to -11º. Postoperatively, most of the cases i.e 74 had less than 5° of varus or valgus deformity, and only one case developed a varus malalignment of +7º. In another similar study by Kumar A et al., postoperatively, three patients had >5° varus deformity and 10 patients had <5°valgus deformity with only one patient being >7° (14). In the present study, five patients had varus and valgus >5°, and 25 patients had <5° after surgery.

According to the (Table/Fig 9), in a study by Kulkarni SG et al., antecurvatum to recurvatum deformity range was +8 to -17º (13). Postoperative, cases had 0° deformity in 65 cases, seven had a deformity of <3°, and three patients had a deformity of 4-9°.

Of the 75 cases preoperatively, 28 cases had recurvatum, 40 had procurvatum, and 17 had 0° deformity. In the present study, antecurvatum to recurvatum deformity range varies from +18 to -24º. Postoperatively, none of the patients had deformity >3º. The results of the study by Kulkarni SG et al., were similar to the present study (13). In a study by Hussain T et al., postoperatively 32 cases had 0°, two had a 0-3° and one had 4° similar to the present study (15).

In the present study, shortening of the leg was observed in 6.6% of patients, 13.33% and 10% observed, movement loss in the ankle and knee respectively, while muscle wasting and subtalar movement loss were observed in 20% each. One patient had a superficial skin infection (oozing of purulent discharge from distal locking skin suture site) treated with prolonged antibiotics. In a study by Bhangadiya R related to Poller screw, no complication was noticed (16). In 30 cases after the radiographic union of bone, nail, and screw removal was done. Full quadriceps strength, with no flexion deformity and ligamentous instability, was experienced in all cases. In postoperative complications, five patients had pain in the anterior knee joint and two patients had superficial infections, which were treated with debridement of local tissue and by inserting antibiotic-impregnated beads. Kulkarni SG et al., reported anterior knee joint pain in eight patients and superficial infections in four patients, as a postoperative complication, which was managed by debridement locally and by inserting antibioticimpregnated beads (13). As compared to IM nailing alone, Guo J et al., reported non union in 0%, malunion in 3%, and need for secondary surgical procedures only in 3% of cases and they also experienced shorter fracture healing time by augmenting IM nail with Poller screws (17).

All the patients completed the study and the functional evaluation criteria by Karlström-Olerud for measuring the functional outcome yielded results that were in favor of the results for radiological and clinical signs of union.

Limitation(s)

However, the sample size was small; therefore, within the limitations of the study, future research with larger sample size is recommended to further ascertain the findings of the index study.

Conclusion

Poller screws used with IM nailing help in achieving fracture alignment by functionally decreasing the medullary width and by improving bone-implant construct stability. It also keeps the fracture aligned until it is healed, preventing the loss of the initial reduction. So from the present study, it is suggested that that pollar screws can be used in proximal 1/3rd and distal 1/3rd of shaft tibial fractures for achieving better fracture alignment.

References

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Krettek C, Stephan C, Schandelmaier P, Richter M, Pape HC, Miclau T, et al. The use of Poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails. The Journal of Bone and Joint Surgery. British volume. 1999;81(6):963-68. [crossref]
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Tennyson M, Krkovic M, Fortune M, Abdulkarim A. Systematic review on the outcomes of poller screw augmentation in intramedullary nailing of long bone fracture. EFORT open reviews. 2020;5(3):189-03. [crossref] [PubMed]
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Kumar A, Panda KK, Singh A, Singh AK. Intramedullary Interlocked Nail with Poller Screw Guidance for management of Extra-articular Proximal Tibial Fractures: A Prospective Study. Int J Cur Res Rev| Vol. 2020;12(18):95. [crossref]
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Seyhan M, Kocaoglu B, Gereli A, Nalbantoglu U, Turkmen M. Treatment for distal tibial fractures with intramedullary nails and blocking screws. European Journal of Orthopaedic Surgery & Traumatology. 2012;22(5):395-01. [crossref]
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Dr. Bandaru Balakrishna, Dr. VV Vinay Vivek, Dr. K Satya Kumar. Role of various modalities in the management of compound grade 3A and 3B fractures of tibia. Int J Orthop Sci. 2019;5(3):131-37. Doi: 10.22271/ortho.2019.v5.i3c.1518 [crossref]
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Kulkarni SG, Varshneya A, Kulkarni S, Kulkarni GS, Kulkarni MG, Kulkarni VS, et al. Intramedullary nailing supplemented with Poller screws for proximal tibial fractures. Journal of Orthopaedic Surgery. 2012;20(3):307-11. [crossref] [PubMed]
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Guo J, Zha J, Di J, Yin Y, Hou Z, Zhang Y, et al. Outcome Analysis of Intramedullary Nailing Augmented with Poller Screws for Treating Difficult Reduction Fractures of Femur and Tibia: A Retrospective Cohort Study. Biomed Res Int. 2021;2021:6615776. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/57214.17202

Date of Submission: Apr 20, 2022
Date of Peer Review: May 28, 2022
Date of Acceptance: Sep 08, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 23, 2022
• Manual Googling: Sep 01, 2022
• iThenticate Software: Sep 08, 2022 (20%)

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