Characteristics, management, and outcomes of spontaneous osteonecrosis of the knee in Indian population.

PURPOSE: Spontaneous osteonecrosis of the knee affects the medial femoral condyle in patients above 55 years of age. Many reports and studies are available from western countries. But there is a gross paucity of literature on spontaneous osteonecrosis of the knee (SPONK) in the Indian subcontinent, either it is under-reported or detected at a later stage. The aim of our study was to detect SPONK in Indian population and describe its characteristics, treatment, and outcome. MATERIAL AND METHOD: A prospective study was conducted over a period of three years. All patients above 18 years with knee pain at rest and medial condyle tenderness without joint laxity were evaluated with plain radiographs and MRI. Further tests were done if radiological signs of osteonecrosis were present. Various parameters were recoded like Visual Analog Scale (VAS), Knee Society Score (KSS), and MRI Osteoarthritis Knee Score. Conservative treatment consisted of a combination of NSAIDs and bisphosphonates. Decompression with bone grafting was done if there was no improvement or deterioration at three month follow-up. RESULTS: Ten patients were diagnosed with SPONK. The mean age was 50 years with male predominance (60%) with the involvement of medial femoral condyle (80%) or left knee (70%). Most cases were in Koshino stage 1. Mean VAS was 6.5 and mean KSS was 59. All clinical parameters showed improvement at one year. DISCUSSION: A study with a bigger sample size and longer follow-up is needed to fill the lacunae of literature on this topic from the Indian subcontinent. In spite of the limitations, we did observe that in our population, males were more commonly affected than females, which is contrary to most studies on the subject. Also, the disease had an early age of onset (50 years) in Indian population as compared to Western and East Asian populations. CONCLUSION: Combined therapy of NSAIDs and bisphosphonates shows excellent results over a period of one year. Joint-preserving surgeries are effective even in Koshino stage 3 SPONK.

Xanthogranulomatous Osteomyelitis of Proximal Femur Masquerading as Benign Bone Tumor.

We describe a case of xanthogranulomatous osteomyelitis (XO) of the proximal femur in a 65-year-old woman who presented with pain of 6 months' duration in the right hip. Plain radiographs showed a lytic well-defined lesion in the right peritrochanteric region suggestive of a benign neoplastic etiology. The gross and histopathologic examination of the curettage specimen was consistent with XO. Xanthogranulomatous osteomyelitis is a rare chronic inflammatory process that is characterized by the presence of a large number of lipid-containing macrophages with an admixture of lymphocytes, plasma cells, and neutrophils. Gross and radiologic examination of this entity can mimic malignancy, and differentiation should be confirmed by histopathologic evaluation. To the best of our knowledge, XO of the femur has not been reported in the English-language literature. The rarity of this condition and its resemblance to bone tumors form the basis of this case report.

The role of tranexamic acid in reducing blood loss in total knee replacement.

BACKGROUND: Total knee arthroplasty is associated with significant perioperative blood loss which may necessitate blood transfusion. In this prospective randomised case control study we analysed the efficacy and safety of tranexamic acid in reducing perioperative blood loss and requirement of blood transfusion in total knee arthroplasty. METHODS: Fourteen patients (group A) undergoing total knee replacement were given intravenous tranexamic acid twice, once ten minutes before tourniquet deflation and once after four hours. Thirteen patients (group B) were observed as a separate group without the administration of the drug. Total perioperative blood loss, need of blood transfusion and D-dimer assay were analysed subsequently. RESULTS: The average blood loss in the first group was 266.2 ml and in the second group was 667.5 ml (p < 0.001). average requirement of transfusion in both the groups were 0.54 and 1.6 units of blood respectively (p < 0.001). There was no case of deep vein thrombosis or any other untoward effects. CONCLUSION: Hence from these evidences it was concluded that administration of tranexamic acid during total knee replacement helps to reduce blood loss without increasing the risk of deep vein thrombosis.

Management of idiopathic clubfoot in toddlers by Ponseti's method.

The Ponseti method has been reported to have successful results in clubfoot patients less than 6 months of age but the literature on its efficacy in older clubfoot patients still remains sparse. In our study, we prospectively evaluated 55 clubfeet (37 patients) to determine clinically whether the Ponseti method is effective in the management of clubfoot in older children between the age of 12 and 36 months (mean: 24.8 months). All the patients belonged to moderate or severe grades of deformity as per the Pirani scoring. Painless, supple, plantigrade and cosmetically acceptable feet were achieved in 49 clubfeet. Seven patients (seven feet) developed recurrence of adduction, varus and equinus deformity whereas three patients (five feet) developed isolated recurrence of equinus deformity. These seven patients responded to repeat treatment and obtained satisfactory outcome. Four of these seven patients underwent tibialis anterior transfer to third cuneiform for dynamic supination. Three patients, those developed isolated recurrence of equinus deformity, underwent repeat tenotomy. One foot achieved satisfactory amount of dorsiflexion, three feet underwent tendoachilles lengthening whereas another foot underwent posterior release to obtain satisfactory dorsiflexion. Six to 12 numbers of casts (mean: 10) were required to obtain correction of clubfoot deformities. Mean period of immobilization in a cast was 13.9 weeks (10-15 weeks). We found that the Ponseti method is effective in children between the age of 12 and 36 months.