Outcomes of one-stage reconstruction for chronic multiligament injuries of knee.

PURPOSE: This article aims to evaluate patterns of chronic multiligament injuries and outcomes of treatment with single-stage reconstruction using autografts. METHODS: All patients with clinicoradiologically diagnosed multiligament knee injury (MKI) were included in this prospective observational study. As the time since injury was more than 6 weeks in all of the patients, they were categorized as having chronic MKI. Patients were assessed clinically for laxity, and the diagnosis was confirmed radiologically. Ipsilateral hamstring tendons were used for medial collateral ligament (MCL) or posterolateral corner reconstruction in a patient with Schenck knee dislocation (KD) type III. In these cases, the posterior cruciate ligament (PCL) and anterior cruciate ligament (ACL) were reconstructed by using the peroneus longus and contralateral hamstring tendons respectively. Ipsilateral hamstring tendons were used for ACL reconstruction and an ipsilateral peroneus longus tendon graft was used for reconstruction of the PCL in a KD type II injury. In two cases of KD type IV injury, the lateral laxity was only grade II and was managed conservatively; the rest of the ligaments were addressed like a KD type III injury. Outcome evaluation was done using a visual analogue scale (VAS) for pain, International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity level, preoperatively and postoperatively at 2 years' follow-up. RESULTS: A total of 27 patients of mean age 33.48 ± 9.9 years with MKI were included in the study. The patients were classified as eight KD type II, 17 KD type III, and two KD type IV. The majority of the patients had associated meniscal (59.2%) or chondral (40.7%) injuries. At the 2 years' follow-up visit, there were significant improvements in VAS score (p = 0.0001) IKDC score (p = 0.0001), Lysholm score (p = 0.0001), and range of motion (p = 0.001). None of the patients had residual laxity on clinical examination of the knee joint at the 2 years' follow-up. All but two of the patients went back to their previous activity level. These two patients had progressive knee arthritis and needed knee arthroplasty. CONCLUSION: Single-stage surgical reconstruction for chronic MKI has favourable functional outcomes. LEVEL OF EVIDENCE: Level IV, case series.

Pig Bite Injury Mimicking as Battered Baby Syndrome Leading to Bilateral Foot Amputation in a Toddler: A Diagnostic Dilemma and a Rare Case Report.

INTRODUCTION: Animal bites are a less common cause of pediatric injury. They are rarely associated with fractures in toddlers. Child abuse is the most closely related differential diagnosis in a child presenting with animal bite and it is a serious threat to both mental health and physical well-being of pediatric population. In all such cases with diagnostic dilemma, battered child syndrome (BCS) needs to be ruled out and reported. To the best of our knowledge, there has been no case report of bilateral femur fracture after a pig bite injury in a toddler with gangrene of bilateral foot. Hence, we report this case to highlight the importance of differentiating animal bite injuries to BCS. CASE REPORT: We report a rare case of pig bite injury with bilateral femur fracture and bilateral foot gangrene in a case of an 11-month-old female child suffering from BCS. CONCLUSION: Apart from the medical and surgical management of pediatric injuries, it is essential to determine the cause of pediatric fractures and differentiate between abuse and accidental trauma. Identification of the etiology is significant to make sure that proper multidisciplinary intervention is initiated for the safety of the child.

Combined Talus Fracture with Medial Malleolar Fracture: A Case report with Review of Literature.

INTRODUCTION: Combined talar body fracture with a medial malleolar fracture is rare in literature. CASE PRESENTATION: A 30-year-old female presented to our hospital with complaints of pain and swelling over the right ankle joint with difficulty in bearing weight following a motor vehicle accident. Investigation showed talar body fracture of type 2 Sneppen (classification) with an ipsilateral medial malleolar fracture. Fractured talus was openly reduced with the help of reduction clamp and appropriate sized Herbert screw applied to hold the reduction. The medial malleolar fracture was fixed with an appropriate-sized cannulated cancellous screw after confirming satisfactory reduction. The patient was followed up for wound complications, AVN changes, early osteoarthritic changes, and functional outcome. CONCLUSION: The combined talar body fracture, ankle dislocation with a medial malleolar fracture, should be managed; as soon as, a diagnosis is made to get a good functional outcome, even though the incidence of skin complication, AVN risk, and post-traumatic ankle arthritis could not be predicted even though it was absent in our case.

Volumetric modulation arc radiotherapy with flattening filter-free beams compared with static gantry IMRT and 3D conformal radiotherapy for advanced esophageal cancer: a feasibility study.

PURPOSE: A feasibility study was performed to evaluate RapidArc (RA), and the potential benefit of flattening filter-free beams, on advanced esophageal cancer against intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT). METHODS AND MATERIALS: The plans for 3D-CRT and IMRT with three to seven and five to seven fixed beams were compared against double-modulated arcs with avoidance sectors to spare the lungs for 10 patients. All plans were optimized for 6-MV photon beams. The RA plans were studied for conventional and flattening filter-free (FFF) beams. The objectives for the planning target volume were the volume receiving ≥ 95% or at most 107% of the prescribed dose of <1% with a dose prescription of 59.4 Gy. For the organs at risk, the lung volume (minus the planning target volume) receiving ≥ 5 Gy was <60%, that receiving 20 Gy was <20%-30%, and the mean lung dose was <15.0 Gy. The heart volume receiving 45 Gy was <20%, volume receiving 30 Gy was <50%. The spinal dose received by 1% was <45 Gy. The technical delivery parameters for RA were assessed to compare the normal and FFF beam characteristics. RESULTS: RA and IMRT provided equivalent coverage and homogeneity, slightly superior to 3D-CRT. The conformity index was 1.2 ± 0.1 for RA and IMRT and 1.5 ± 0.2 for 3D-CRT. The mean lung dose was 12.2 ± 4.5 for IMRT, 11.3 ± 4.6 for RA, and 10.8 ± 4.4 for RA with FFF beams, 18.2 ± 8.5 for 3D-CRT. The percentage of volume receiving ≥ 20 Gy ranged from 23.6% ± 9.1% to 21.1% ± 9.7% for IMRT and RA (FFF beams) and 39.2% ± 17.0% for 3D-CRT. The heart and spine objectives were met by all techniques. The monitor units for IMRT and RA were 457 ± 139, 322 ± 20, and 387 ± 40, respectively. RA with FFF beams showed, compared with RA with normal beams, a ∼20% increase in monitor units per Gray, a 90% increase in the average dose rate, and 20% reduction in beam on time (owing to different gantry speeds). CONCLUSION: RA demonstrated, compared with conventional IMRT, a similar target coverage and some better dose sparing to the organs at risk; the advantage against conventional 3D-CRT was more evident. RA with FFF beams resulted in minor improvements in plan quality but with the potential for additional useful reduction in the treatment time.