When Marriage Hurts: A Literature Review of Embedded Jewellery Ring Injuries.

A ring is traditionally worn as a symbol of love and affection or as decorative ornamental jewellery. However, rings are not without risk. The spectrum of danger can range from debilitating avulsion injuries to simple contact dermatitis. Unknown to many, an unusual rarity exists; previous authors have termed this entity 'embedded ring syndrome'. We sought to review the literature and collate evidence on the common features of this syndrome. A literature review was performed on cases reported from 1947 to 2017 accessed through the healthcare database advanced search (HDAS). A total of 28 cases were analysed for demographics, symptomatology and operative techniques. Overall, 64.3% were females, and 50% had a psychiatric comorbidity. There was a causative event preceding the injury in 35.7% of cases; 71.4% had a reduced range of movement or reported a stiff finger and 32.1% had reduced sensation. The majority of patients underwent ring removal and primary closure, without documentation as to whether neurovascular bundles and tendons were visualised. Embedded ring injuries are rare. Consequently, information is sparsely available regarding its natural history and management. The hand surgeon's approach requires an understanding that the chronicity of these injuries can have a significant traumatic impact on the structures of the finger.

Outcome of Single Stage Revision ACL Reconstruction. Retrospective Study and Review of Literature.

BACKGROUND: Pragmatic review of outcomes for single stage revision ACL reconstruction performed in a single center and the reasons for failure in primary surgery. MATERIAL AND METHODS: Retrospective study included 59 patients with revision ACL reconstruction done by one surgeon from 2007 to 2017.Clinical records, operative notes and x-rays were assessed to find the reasons of failure. RESULTS: The cause of failure was traumatic in 26 (44.1%) patients after primary reconstruction, incorrect tunnel position in 18(30.5%) and biological failure in 15 (25.4%). All ACL revisions were done using autografts; patellar tendon grafts in 33 patients (55.9%), ipsilateral hamstrings in 12 (20.3%), contralateral hamstrings in 9 (15.3%) and quadriceps tendons in 5 (8.5%). Twenty-one patients were contactable as regards postoperative functional outcome scores. There was an average 18 point improvement in Oxford knee score (OKS) post-operatively, 1.6 point improvement in Tegner scores and 30 point improvement in Lysholm scores. One patient (1.7%) developed septic arthritis, 4 (6.8%) had superficial infection, while 6 (10.2%) had residual instability after revision but did not have further surgery. There was lack of full extension in 4 (6.8%) patients. In BTB grafts, 2 (6.1%) patients sustained a post-traumatic patellar fracture. CONCLUSIONS: 1. Good outcomes of single stage revision ACL reconstruction surgery are achievable as de-monstrated in our cohort. 2. There is need for good quality research to identify whether BTB, hamstrings or quadriceps autografts are better for ACL Reconstruction.

Is vitamin D deficiency behind the scenes for high incidence of Giant cell tumor amongst the Indian population? Unraveling the vitamin D - RANKL association.

INTRODUCTION: The major neoplastic and proliferative component of GCTB is the stromal tumor cells; that they have shown no evidence of bone destruction, instead the massive tissue destruction appears to be a result of tumor induced osteoclastogenesis. The discovery of receptor activator of nuclear factor kB (RANK) and RANK binding ligand (RANKL) uncovered the bone homeostasis and molecular mechanism by which multiple compounds (including vitamin D) regulated osteoclast differentiation; a function mediated by osteoblastic cells and osteoclast-precursor cells. HYPOTHESIS: In a country burdened by vitamin D deficiency, causal relation between hypovitaminosis D and GCTB was hypothesized based on the vitamin D mediated RANKL expression and osteoclastogenesis, as India is also a population with higher incidence of GCTB as compared to Western populations described in the literature. The possibility of vitamin D regulated osteoclastogenesis in GCTB is postulated on the evidence from molecular research linking it to the RANK/RANKL/OPG pathway. The aim of this study was to analyse the prevalence of Vitamin D deficiency in patients with primary GCTB and to elucidate any difference in serum Vitamin 25(OD)D3 levels amongst the matched control population data. MATERIALS AND RESULTS: 130 patients of primary GCTBs were matched to 310 controls from the general health check population and serum levels of 25(OH)D3 were analyzed. Statistical analysis performed on the non-parametric data and Mann Whitney U Test used to derive inference with significance set at p < 0.05. 56 females and 76 males with median Vitamin D level in the GCTB group was 15.9 ng/ml (Mean 19.41; Range 1.03 to 92) as compared to the control population with median level of 22.2 ng/ml (Mean 25.1; Range 2.6 to 87.9). The results were significant (p value < 0.05) as compared to the control population in all decades except the third decade (p value 0.0548). DISCUSSION: The differential expression of RANKL and OPG in response to levels of vitamin D has been established. The stromal cells of osteolytic GCTB express high levels of RANKL, which is a key signal regulator in development of this disease and bone destruction typical of GCTBs. This has resulted in research targeting this pathway for therapeutic approach in GCTBs. As vitamin D supplementation is simple and safe, increased awareness to assess and if necessary correct vitamin D status of patients is warranted, however the question as to whether patients with low vitamin D levels are more prone to develop GCTB and thus would profit from vitamin D supplementation remains unanswered. To conclude, it is essential to assess vitamin D levels in patients with GCTB as deficiency is pronounced. Future research on this hypothesis might lead to an association between Vitamin D deficiency and the onset/natural history of GCTB that may in the future help us cure or prevent GCTBs.