Cage Augmentation of the Retained Acetabular Shell with a Dual Mobility Cup using the Double Socket Technique.

Introduction: Prevention of dislocation after total hip arthroplasty (THA) remains a topic of debate. There are various surgical options to manage hip instability such as large femoral heads, and constrained liners, although the best option to tackle this is still controversial. In revision scenarios with previous well-fixed acetabulum shells, the cementation of polyethylene liners or the cementation of dual mobility (DM) into a well-fixed acetabulum shell (Double Socket Technique) has been documented before.Here, we report a case of re-revision THA, where we have used the Double Socket Technique of retaining the previous well-fixed acetabular shell with the cementation of the DM cup along with an anti-protrusio cage inside the socket. To the best of our knowledge, this is the first such a case to be reported worldwide. Case Report: A 54-year-old male who underwent THA in 1990 and an acetabulum cup revision in 2003 presented to us with right hip pain. Radiographs showed Paprosky Type 3A femoral bone loss and polyethylene wear. Intraoperatively after removing the polyethylene liner, the acetabulum shell was found to be well fixed and therefore retained. To increase stability, an anti-protrusio cage was inserted over it and a DM cup was cemented onto it (double socket). The femoral stem was revised using Wagner stem and encerclage wires and a hook plate was used to stabilize the osteotomy site. Conclusion: This technique is a reliable option and helps shorten the surgical time and reduce the bone loss that can occur in extracting a well-fixed acetabulum shell. The use of a DM cup decreases the chances of instability compared to the cementation of polyethylene liners and decreases the high failure rate associated with the use of cementation of constrained liners. The addition of an anti-protrusio cage in addition to the Double Socket Technique increases the stability of the construct.

Bisphosphonates for Post-COVID Osteonecrosis of the Femoral Head: Medical Management of a Surgical Condition.

COVID-19 infection can cause long-term effects, cumulatively known as long COVID syndrome. One such sequela is osteonecrosis of the femoral head (also called avascular necrosis of the femoral head, or AVNFH). On the basis of our 20-year experience in using bisphosphonate therapy in the successful management of osteonecrosis, we conducted the present study to evaluate the efficacy of the therapy in the management of post-COVID osteonecrosis of the femoral head. In addition, we aimed to evaluate the cumulative dosage of corticosteroids and the duration between the commencement of corticosteroids and the development of osteonecrosis in COVID-19 survivors. Methods: This was a retrospective evaluation of 48 patients (88 hips) diagnosed with osteonecrosis of the femoral head at a tertiary care center after COVID-19 infection between September 2020 and May 2021. Patients received intravenous zoledronic acid (5 mg) at the initiation of therapy and oral alendronate (35 mg) twice weekly, and were followed for a minimum of 6 months. Clinical evaluation was conducted using a visual analog scale (VAS) for pain and the Harris hip score (HHS). Radiographic evaluation was performed to assess the progression of the disease and collapse of the femoral head. Results: At a mean follow-up of 10 months, 84 (95.5%) of the hips showed good clinical outcomes, and only 4 (4.5%) of the hips required surgical intervention. The mean VAS pain score and HHS improved at 6 weeks and steadily improved on subsequent follow-ups. In 16 (18%) of the 88 affected hips, radiographic progression was observed. The mean dose of corticosteroids administered to the patients to manage COVID-19 infection was 841.3 mg of prednisolone equivalents. The mean duration between the commencement of corticosteroid therapy and the development of osteonecrosis was 179 days. Conclusions: Post-COVID osteonecrosis appears to be more aggressive, with COVID-19 itself contributing to its etiopathogenesis in addition to corticosteroids. However, it can be diagnosed by magnetic resonance imaging (MRI) in symptomatic patients and then effectively treated medically, especially if detected in the early stages. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Secondary osteonecrosis of the knee as a part of long COVID-19 syndrome: a case series.

COVID-19 infection affects different organ systems with long-term sequelae, which has been termed as long COVID-19 syndrome. To the best of our knowledge, osteonecrosis of the knee as a part of long COVID-19 syndrome has not been documented. Corticosteroids are being used extensively in moderate and severe cases of COVID-19. We report two cases who developed osteonecrosis of the knee after being treated for COVID-19 infection. In our case series, the mean cumulative dose of prednisolone was 1156.5 mg (900-1413 mg), which is less than the cumulative dose reported in literature for osteonecrosis of the knee. In our case series, the patients developed symptomatic osteonecrosis at a mean interval of 73 days after initiation of steroid therapy, with the earliest presenting at 25 days. Early diagnosis of osteonecrosis of the knee on high clinical suspicion by MRI would help in early intervention with bisphosphonate therapy.

Predictive factors affecting long-term survivorship of ASR metal-on-metal total hip arthroplasty.

INTRODUCTION: We present the outcome of 154 ASR (Articular Surface Replacement) hips performed at the P.D Hinduja Hospital and Medical Research Centre in terms of revision rate, metal ion levels, and factors affecting survivorship. Further, determined the importance of serial metal ion estimation over single value with poorly functioning arthroplasties. METHODS: A retrospective study of 154 ASR arthroplasties (136 patients) performed from April 2005 till March 2010 was conducted. Ninety-seven patients were available for final analysis. All patients were assessed for symptoms, radiographs, blood metal (chromium and cobalt), metal artefact reduction sequence (MARS), magnetic resonance imaging (MRI), and computerized tomography (CT). RESULTS: Female gender, smaller femoral head, patients with a rising level of metal ion levels were more likely to have revision surgery. However, abnormal acetabular inclination/anteversion was not associated with the occurrence of raised metal ion levels, ARMD (adverse reaction to metal debris) or revision surgery. Patients with raised metal ion levels were more likely to have periprosthetic lucency, ARMD, and revision surgery. Median metal levels increased initially for the first three years. Still, patients who required revision surgery continued to have a metal ion rise until the point when revision surgery was performed. In contrast, patients who had a fall in metal ion levels did not require revision. CONCLUSION: A single metal ion value is less predictive of failing arthroplasties; instead, a rising trend of metal ion levels can better delineate arthroplasties which will require revision. ASR hips whose blood ion levels fell after an initial rise and showed a declining trend did well.

Superior functional outcome with dual mobility THR as compared to conventional THR in fracture neck femur: a prospective cohort study.

INTRODUCTION: Total Hip Replacement (THR) in displaced Fracture Neck of Femur (FNOF) is associated with higher dislocation rates. Conventional THR with a large femoral head and anterior approach has reduced the instability, but it remains higher than THR done for other aetiology. Recent studies have shown reduced dislocation rates with dual mobility THR (DMTHR) for FNOF; however, there is a lack of comparative research to show its superiority over conventional THR. Further, its role in the Asian subcontinent, where the patient requires sitting cross-legged or squatting, has not been studied. METHODS: A prospective cohort study of 103 elderly patients with displaced FNOF with a minimum follow-up of 1-year. Fifty-two patients were operated on with DMTHR and fifty-one patients with conventional THR. Both the groups were matched in terms of demographic data, surgical approach, and postoperative protocol. Radiological and functional outcomes in terms of Harris Hip Score (HHS), Range of motion, Patient Reported Outcome Measures (PROM), and Dislocation rate were compared between the two groups. RESULTS: Mean HHS of the DMTHR group was 76.37 at three months and 87.02 at the end of the 1-year postoperatively, which was significantly better than the conventional THR group 65.65 at three months and 72.96 at 1-year. The range of motion was significantly better in the DMTHR group than the conventional THR group. There was no significant difference in radiological outcomes and postoperative dislocation rate between the two groups. CONCLUSION: Dual mobility implants give better results than conventional implants for primary THA in elderly patients of displaced FNOF regarding better function and greater range of motion.

Avascular necrosis as a part of 'long COVID-19'.

'Long COVID-19' can affect different body systems. At present, avascular necrosis (AVN) as a sequalae of 'long COVID-19' has yet not been documented. By large-scale use of life-saving corticosteroids in COVID-19 cases, we anticipate that there will be a resurgence of AVN cases. We report a series of three cases in which patients developed AVN of the femoral head after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 758 mg (400-1250 mg), which is less than the mean cumulative dose of around 2000 mg steroid, documented in the literature as causative for AVN. Patients were symptomatic and developed early AVN presentation at a mean of 58 days after COVID-19 diagnosis as compared with the literature which shows that it generally takes 6 months to 1 year to develop AVN post steroid exposure.

Dual mobility THR: Resolving instability and providing near normal range of movement.

BACKGROUND: Dislocation is a common complication of Total Hip Replacement (THR), particularly when performed in primary (indications with increased risk of instability) and in revision scenarios. Dual mobility THR (DMTHR) minimizes the risk of instability in such scenarios, however most of the evidence is from western literature. Results of DMTHR in Indian scenarios where patient want to go back to their normal routine activities of squatting and sitting cross-legged is lacking. The aim of our study was to evaluate the short to mid-term results of DMTHR for varied indications (both primary and revision) in Indian scenario. To evaluate the outcome of the DMTHR in terms of functional range of motion and the ability to go back to their pre-injury level of activity. METHODS: This is a retrospective study of 150 patients operated with DMTHR between January 2015 to February 2019 with a minimum follow-up of 12 months. Patients were evaluated clinically using Modified Harris Hip Score (HHS), Range of Motion (ROM), and Patient Reported Outcome Measures (PROM) like ability to squat and sit cross legged. Radiological evaluation was done using radiographs to assess loosening, stress shielding, osteolysis. RESULTS: Mean follow up in our study was 25.2 months (Range 12-46 months). Mean Modified HHS was 71.8 ± 8.11 at 6 weeks post-op and 85.8 ± 7.62 at last follow-up. HHS showed excellent outcome in 36 hips (26.7%), good outcome in 76 hips (56.7%), fair outcome in 20 hips (14.6%), poor outcome in 3 hips (2%). All our patients were allowed to squat and sit cross-legged at a mean follow-up period of 13 weeks (8 weeks-20 weeks) except 10 cases of Revision THR where patients were advised not to squat or sit cross-legged. All patients were able to resume their activities of daily living. CONCLUSION: DMTHR in patients of all ages has shown a good short to midterm clinical outcome which is comparable to conventional THR. It confers the benefit of stability allowing our patients to squat and sit cross legged which is often one of the expectation and requirement of a patient undergoing THR in India. DMTHR in both primary and revision scenarios exhibit a low risk of dislocation, complications and revision surgery.

Repurposing denosumab for recalcitrant bone healing.

Fracture healing has four phases: haematoma formation, soft callus, hard callus and remodelling. Often, non-healing fractures have an arrest of one of these phases, which need resurgery. We have repurposed denosumab for impaired fracture healing cases to avoid surgical intervention. Here, we report a series of three cases of impaired fracture healing where denosumab was given 120 mg subcutaneous dosages for 3 months to enhance healing. All the three cases have shown complete bone union at a mean follow-up of 6.7 months (5-9 months) as assessed clinically and radiologically, and have observed no adverse effect of the therapy. Denosumab given in this dose aids fracture healing by increasing callus volume, density and bridges the fracture gap in recalcitrant fracture healing cases where the callus fails to consolidate.

Analgesic effectiveness of Local Infiltrative Analgesia alone versus combined single dose adductor canal block with Local Infiltrative Analgesia: A single centre case control study.

BACKGROUND: Both adductor canal block (ACB) and of Local Infiltrative Analgesia (LIA) have been shown to reduce pain after total knee arthroplasty (TKA). The efficacy of combining ACB and LIA remains controversial. The objective of this study is to analyse the effect of LIA + single dose ACB compared to LIA alone on early post-operative pain and mobilization in TKA. METHODS: This Cohort Prospective study analyses the Visual Analogue Score (VAS) pain scores and rehabilitation milestones at 24 h between LIA alone and LIA + single dose ACB in unilateral TKA operated by a single surgeon between August 2014 and February 2019. RESULTS: VAS at rest and on movement were significantly better in the combined LIA + ACB group (n = 151) compared to LIA (n = 120) alone at 24 h. All patients were able to achieve the desired milestones of sitting, standing by the bedside and walking with the help of a walker within 24 h of the surgery. CONCLUSION: Though the VAS scores were statistically significant, the actual scores at rest and on movement in both groups were significantly better than preoperative scores with excellent pain relief. All patients in both groups were able to ambulate within 24 h. LIA alone significantly improved the pain scores and enabled early mobilization. Addition of single dose ACB to LIA did not significantly alter the milestones.

Is obesity a contraindication for simultaneous bilateral total knee arthroplasty? A prospective case-control study.

AIM: Total Knee Arthroplasty (TKA) for decades has been an effective treatment modality for chronic arthritis of the knee. However, there is scarcity of literature comparing the functional outcomes of simultaneous bilateral TKA in obese patients with non-obese Indian population. We conducted this study to evaluate the functional outcomes and complication rates of simultaneous bilateral TKA in obese patients matched control with non-obese patients. MATERIALS AND METHODS: We divided the patients into two study groups based on their body mass index (BMI). Patients with a BMI of less than 30 were classified as non-obese and those with a BMI of more than 30 were classified as obese. All the patients underwent simultaneous bilateral TKA by a single surgeon using the same implant and technique. Patients were followed up regularly and functional outcomes in terms of Oxford knee score were noted at 6 weeks, 3 months, and 1 year. Post-operative complications and time to recovery was also compared. RESULTS: Mean follow-up in obese group was 18 months (12-25 months) and in non-obese group was 17 months (12-24 months). Both the groups were matched with control in terms of pre-operative parameters. Post-operative hemoglobin drop, ICU requirement, length of hospital stay, mean walking time, and mean time to climbing stairs were similar in both the groups. Oxford knee score was significantly better in non-obese group at 6 weeks, but was similar in both the groups at 3 months, 6 months, 1 year, and last follow-up. There was no statistically significant difference seen in the complication rate in both the groups. There was no implant loosening or radiolucency seen. CONCLUSION: We conclude in our study that simultaneous bilateral TKA gives comparable mid-term results in obese patients in comparison to the non-obese patients.

Effect of Zoledronic Acid and Alendronate on Bone Edema and Pain in Spontaneous Osteonecrosis of the Knee: A New Paradigm in the Medical Management.

Objective The aim of the present study was to determine the effect of combined zoledronic acid and alendronate therapy on bone edema and knee pain in cases of spontaneous osteonecrosis of the knee. We report our experience with this treatment. Methods A retrospective case series of 11 patients with spontaneous osteonecrosis of the knee confirmed by magnetic resonance image (MRI). The patients were treated with a single dose of 5 mg of intravenous zoledronic acid combined with 35 mg twice a week of oral alendronate, for 16 weeks. The visual analogue scale scores were noted before the beginning of the therapy, at 8 weeks, and at 16 weeks of follow-up. The size of the bone marrow edema adjacent to the lesion was measured on T2-weighted MRI coronal images at the beginning of the therapy and at 16 weeks. Results The average visual analogue scale score at 0 weeks was of 7.72, and of 0.81 at 16 weeks of therapy; the difference was statistically significant ( p = 0.03). The mean bone marrow involvement at 0 weeks was of 80%, which reduced to 11.81% at 16 weeks of therapy. This change was statistically significant ( p = 0.03). Conclusion Our data shows that the combination therapy causes early pain relief and reduction of the bone edema, and it is safe, effective and well-tolerated for a painful disease entity like spontaneous osteonecrosis of the knee.

Effect of Zoledronic Acid and Alendronate on Bone Edema and Pain in Spontaneous Osteonecrosis of the Knee: A New Paradigm in the Medical Management / Efeito do ácido zoledrônico e do alendronato no edema ósseo e dor na osteonecrose espontânea do joelho: Um novo paradigma no manejo

Abstract Objective The aim of the present study was to determine the effect of combined zoledronic acid and alendronate therapy on bone edema and knee pain in cases of spontaneous osteonecrosis of the knee. We report our experience with this treatment. Methods A retrospective case series of 11 patients with spontaneous osteonecrosis of the knee confirmed by magnetic resonance image (MRI). The patients were treated with a single dose of 5 mg of intravenous zoledronic acid combined with 35 mg twice a week of oral alendronate, for 16 weeks. The visual analogue scale scores were noted before the beginning of the therapy, at 8 weeks, and at 16 weeks of follow-up. The size of the bone marrow edema adjacent to the lesion was measured on T2-weighted MRI coronal images at the beginning of the therapy and at 16 weeks. Results The average visual analogue scale score at 0 weeks was of 7.72, and of 0.81 at 16 weeks of therapy; the difference was statistically significant (p= 0.03). The mean bone marrow involvement at 0 weeks was of 80%, which reduced to 11.81% at 16 weeks of therapy. This change was statistically significant (p= 0.03). Conclusion Our data shows that the combination therapy causes early pain relief and reduction of the bone edema, and it is safe, effective and well-tolerated for a painful disease entity like spontaneous osteonecrosis of the knee.

Resumo Objetivo Determinar o efeito do tratamento combinado de ácido zoledrônico e alendronato no edema ósseo e na dor no joelho em casos de osteonecrose espontânea do joelho. A experiência dos autores com este tratamento é relatada. Métodos Série de casos retrospectiva, incluindo 11 pacientes com osteonecrose espontânea do joelho confirmada por ressonância magnética. Os pacientes foram tratados com uma dose intravenosa única de 5 mg de ácido zoledrônico combinada com 35 mg de alendronato oral, 2 vezes por semana, por 16 semanas. Os escores da escala visual analógica foram aferidos antes do começo do tratamento, em 8 semanas e em 16 semanas de acompanhamento. O tamanho do edema da medula óssea adjacente à lesão foi medido em imagens de ressonância magnética coronal ponderadas em T2 no início do tratamento e em 16 semanas. Resultados O escore médio da escala visual analógica em 0 semanas foi de 7,72, contra 0,81 em 16 semanas de tratamento, uma diferença estatisticamente significativa (p= 0,03). O envolvimento médio da medula óssea em 0 semanas foi de 80%, e foi reduzido para 11,81% em 16 semanas de tratamento, uma diferença também estatisticamente significativa (p= 0,03). Conclusão Os dados mostram que a terapia combinada proporciona alívio da dor inicial e redução do edema ósseo, sendo segura, eficaz e bem tolerada em uma enfermidade dolorosa como a osteonecrose espontânea do joelho.

Safety and efficacy of sequential simultaneous bilateral total knee arthroplasty: A single centre retrospective cohort study.

BACKGROUND: Simultaneous bilateral total knee arthroplasty (TKA) is a promising option for patients with bilateral arthritis of the knee because of the requirement of a single hospitalization and anesthetic regimen, reduced overall hospital stay, lower overall costs, and quicker recovery compared to staged bilateral TKA. However, there are conflicting reports on the safety of the procedure, with little data available in the Indian setting. Herein, we compared the efficacy and safety of sequential simultaneous bilateral TKA (SSBTKA) with those of unilateral TKA (UTKA). METHODS: This retrospective analysis included cases of SSBTKA (n = 380, 760 knees) and UTKA (n = 754) performed by the same surgeon and followed up for a minimum duration of 1 year. The functional outcomes (postoperative changes in Oxford Knee Score [OKS] and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), length of hospital stay (LOS), complications, and rates of revision and mortality were compared between the two groups. RESULTS: The mean follow-up durations were 40.59 and 36.69 months for the UTKA and SSBTKA groups, respectively. The LOS was significantly longer in the SSBTKA group than in the UTKA group (Median [Interquartile range]: 4[1] vs. 3[0], p < 0.001). The OKS and WOMAC scores increased with time in both groups. The improvements in each of these scores at 3, 6, and 12 months postoperatively were either statistically similar between the two groups or, if statistically different, the differences were too small to be clinically meaningful. Blood transfusions (4% [SSBTKA] vs.0.3% [UTKA], p < 0.001), cardiac complications (1.6% vs. 0.4%, p = 0.034), urine retention (3.7% vs. 1.2%, p = 0.005), and deep infection (0.8% vs. 0%, p = 0.015) were significantly more frequent in the SSBTKA group. None of the patients in the UTKA group had to undergo revision surgery, whereas in the SSBTKA group, 2 (0.6%) patients underwent revision TKA. The overall mortality rates were low in both groups (0.8% [SSBTKA] and 0.3% [UTKA]), with no significant between-group difference (p = 0.209). CONCLUSION: The functional outcomes and mortality rates associated with SSBTKA are comparable to those associated with UTKA. The risk of complications and the need for revision, although higher with SSBTKA, the actual numbers are low enough to justify its use. Although the LOS in SSBTKA is longer than that in UTKA, it is likely to be shorter than the cumulative LOS for two UTKA procedures (i.e. a staged bilateral TKA). Thus, SSBTKA appears to be a safe and effective choice for appropriately selected patients.

Twisted Plating - A Method of Distal Fibula Fixation.

Objective The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods Of the 62 cases with ankle fractures managed at our institute by the senior author from 1 st January 2012 to 31 st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8-14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86-100) at a mean follow-up of 31.5 months (14-61 months). Conclusions We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.

Incorporation of screwless press-fit acetabular cups and disappearance of polar gaps.

BACKGROUND: Uncemented press-fit acetabular cups without screws rely on the elastic recoil of the bone for its primary stability and tend to leave polar gaps with its use. The clinical significance of these gaps and the functional outcome of the patients with polar gaps is evaluated in this study. METHODS: This comparative analysis was done on 224 cementless primary THA using Deltamotion® Hip System from January 2010 to December 2017. Patients were divided into two groups based on the presence or absence of polar gaps on immediate post-operative radiographs. Patients were observed for their clinical, radiological and functional outcomes with regular follow ups. At each follow-up, patients' clinical outcome was evaluated using the Harris Hip Score (HHS) and Patient Reported Outcome Measures (PROMs). RESULTS: 14 of 224 patients(6.25%) demonstrated polar gaps in their immediate post-operative radiographs. No statistically significant difference was noted in the final mean HHS between the two groups. The polar gaps ranged from 0.5 to 1.8 mm (mean-1.09 mm). None of the patients showed progression of the polar gaps. All patients showed bony ingrowth into the gaps at a mean of 8.57 months. CONCLUSION: The presence of polar gaps in the immediate post-operative radiographs are not of a major clinical significance provided a secure peripheral fit is achieved intra-operatively. The functional outcome and rehabilitation in such patients is at par with that seen in the patients without polar gaps. Disappearance of these polar gaps is a rule rather than an exception.

Decreasing hospital length of stay and enhancing recovery in Total Knee Arthroplasty.

BACKGROUND: Patients undergoing Total Knee Arthroplasty (TKA) typically have early postoperative pain and decreased mobility, especially so in the first 24 h. Achieving a pain free knee in the immediate postoperative period and reducing complications using multimodal pain and blood management protocols forms a keystone in early mobilization and functional recovery. Enhanced Recovery after Surgery pathways (ERASp) since their inception, have significantly improved perioperative care and functional outcomes, thereby reducing the average length of stay (ALOS), complications and overall healthcare costs. ERASp modified suitably for TKA have had encouraging results. We have retrospectively analyzed the outcomes of the ERASp for TKA at our tertiary care centre with equal emphasis on pre-hospital preparations, in-hospital care, and post-hospital discharge. METHODS: All TKA patients operated by the senior author between July 2016 and January 2018 with a minimum one year follow up were included. The outcomes measured were: Visual Analogue Score (VAS) for pain at rest and on movement, milestones, transfusion requirements, postoperative complications, ALOS and functional scores at one year follow-up. RESULTS: 775 patients (392 unilateral TKA {UTKA} and 383 bilateral {BTKA}) met our inclusion criteria. Both groups were comparable demographically. Mean VAS pain scores at rest were 3.15 ±â€¯2.15 on the day of surgery, 2.5 ±â€¯1.86 on the first postoperative day and 2.08 ±â€¯1.81 on the second day, and 6.2 ±â€¯2.38, 5.77 ±â€¯2.34 and 4.71 ±â€¯2.48 on movement respectively in the UTKA group. In the BTKA group, the mean VAS pain scores at rest were 4.39 ±â€¯2.25 on the day of surgery, 3.98 ±â€¯2.36 on the first postoperative day and 3.05 ±â€¯2.12 on the second day and 6.21 ±â€¯2.38, 5.77 ±â€¯2.34 and 4.71 ±â€¯2.48 on movement respectively. 85.49% of UTKA and 77.22% of BTKA patients walked on the day of surgery. Decrease in haemoglobin and transfusion rates were 1.25 ±â€¯0.41 g% and 0.5%, 1.85 ±â€¯0.62 and 3.9% in the UTKA and BTKA groups respectively.The average length of hospital stay (LOS) was 3.98 days. LOS was 3.17 and 4.78 days with 1.55% and 6.05% major complications in the UTKA and BTKA groups respectively.There was a significant improvement in Oxford Knee and WOMAC scores at 3, 6 and 12 months in both groups. CONCLUSIONS: Pain following TKA is a major deterrent in early mobilization thereby delaying functional recovery and increasing ALOS. We recommend our multimodal interdisciplinary protocol to achieve early mobilization, better pain scores and minimize complications, resulting in overall reduced LOS.

Advantages of clamping and drainage over continuous drainage in a total knee arthroplasty.

INTRODUCTION: The use of closed-suction drainage systems after total knee arthroplasty (TKA) is common practice in India, but with no consensus on its use. In this retrospective study, we compared whether clamped or unclamped drainage has any advantages over the other in unilateral TKA. METHODS: Group-A (n = 351) had an unclamped drain removed at 24 h postoperative, with measurement of total drainage at 24 h between January 2011 and February 2013. Group B (n = 349) had drains kept for a total of 8 h-clamped for the first 4 h and unclamped for a further 4, between March 2013 to September 2016. Drainage volume, as well as the hemodynamic markers-hemoglobin (Hb) drop, transfusion rate were evaluated. RESULTS: Mean drain output in Group- A was significantly higher than Group- B (215.64 ml versus 28.34 ml). The postoperative Hb was significantly higher in Group-B (11.46 g/dl versus 10.57 g/dl). Mean Hb drop was significantly higher in Group A (2.16  g/dl versus 1.18 g/dl). The transfusion rates were lower in Group-B, though not statistically significant. CONCLUSIONS: The 4- hour clamping method effectively reduces drain output and fall in hemoglobin. For those who continue using closed suction drains, clamping could prove to be an effective way of reducing post-operative blood loss and the need for transfusions.

Is obesity A contra-indication for a successful total knee arthroplasty?

BACKGROUND: Total Knee Arthroplasty (TKA) is one of the most effective treatment modalities for chronic knee pain and disability. A strong association exists between obesity and early knee osteoarthritis. Various studies on outcomes of TKA in obese patients have been inconclusive. The purpose of this retrospective evaluation is to assess the influence of obesity on outcomes of TKA in Indian patients. METHODS: This retrospective study conducted from 2010 to 2016 included 402 knees in 213 patients with Body Mass Index (BMI) between 30 and 39.99 kg/m2 followed up for a minimum of 12 months. All cases of revision TKAs and those with follow up less than a year were excluded from the study. Patients were followed up regularly for examining their wound healing, post operative complications if any and knee range of motion. Regular radiographs were taken to observe any evidence of loosening. Post-operative knee society scores(KSS) were recorded at each follow up. Improvement in the scores and activity level was noted. RESULTS: The objective KSS improved from 55.88 to 93.01 at the last follow up while the functional scores improved from 52.91 to 80.63. Post surgery improvement in activity level was seen in 71.83% patients. Complications seen in the study included patello-femoral pain, superficial wound infections, deep vein thrombosis and delayed wound healing. No cases of deep infection or revision surgeries were seen in our series. CONCLUSIONS: The outcome of TKA in non-morbidly obese patients is comparable to non-obese patients with excellent post-operative objective and functional scores. The benefits are sustainable over a long duration of time. The complication rates in obese patients is no different than non-obese patients.

Twisted Plating - A Method of Distal Fibula Fixation / Uso de placa retorcida - Um método de fixação da fíbula distal

Abstract Objective The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods Of the 62 cases with ankle fractures managed at our institute by the senior author from 1st January 2012 to 31st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8-14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86-100) at a mean follow-up of 31.5 months (14-61 months). Conclusions We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.

Resumo Objetivo A literatura discute diversos métodos intramedulares ou extramedulares para fixação de fraturas da fíbula distal, mas não há consenso acerca do método ideal de fixação. Analisamos retrospectivamente os resultados do uso de uma placa bloqueada de compressão (LCP) de 3,5 mm retorcida e com contorno como placa de apoio posterior. Métodos Dos 62 casos de fraturas de tornozelo tratadas em nosso instituto pelo autor sênior entre 1° de janeiro de 2012 e 31 de dezembro de 2015, 41 pacientes atenderam aos critérios de inclusão (tipos B e C de Danis-Weber). Resultados Todas as 41 fraturas fibulares distais cicatrizaram sem intercorrências, em uma média de 10,4 semanas (8-14 semanas) (Figuras 6 a 9) e sem complicações. A pontuação American Orthopaedic Foot & Ankle Society (AOFAS) média foi de 92,6 (86-100) em um período médio de acompanhamento de 31,5 meses (14-61 meses). Conclusões Obtivemos excelentes resultados clínicos e radiológicos com uso de LCP retorcida de 3,5 mm como apoio posterior ao combinar as vantagens da placa antideslizante posterior e a LCP lateral.

TFNA Implant Failure with Helical Blade Cut-out.

INTRODUCTION: Trochanteric femoral nail-advanced (TFNA) was introduced in the market with better nail design, better alloy (titanium molybdenum) and both sliding and static locking options of the helical blade. Although, it was devised to overcome the shortcomings of roximal Femoral Nail Anti-rotation (PFNA), it still can have complications, if the principles of fracture management are not met. Here, we report a case of a TFNA implant failure with helical blade cut-out in an elderly osteoporotic patient treated for inter-trochanteric femur fracture. To the best of our knowledge, this is the first report of helical blade cut-out wit TFNA nail in world literature. CASE REPORT: An 83-year-old female patient was treated with a TFNA nail for inter-trochanteric femur fracture (AO 31A2.1). An acceptable reduction and stable fixation were achieved. The position of the helical blade in the head was in the optimal position with a tip apex distance (TAD) of 29 mm. The patient presented to us 6 weeks later with implant failure with helical blade cut out after a history of fall. Cemented bipolar hemiarthroplasty with calcar reconstruction using a mesh was done. The patient was clinically asymptomatic and was walking full weight-bearing till her last follow-up at 14 months. CONCLUSION: We can associate the failure seen in our case with an increased TAD of 29 mm, osteoporotic bone and a neutral to negative variance. Helical blade cut-out was seen as the blade was locked onto the nail with insufficient hold onto the osteoporotic head fragment which collapsed into varus, leading to cut-out. This case report emphasizes the importance of TAD, valgus reduction, and positive variance in avoiding implant failures, even with a newer implant like TFNA which was developed to improvise onto the shortcomings of PFNA nail.