Arthroscopic debridement of the ankle in synovitis.

Inflammation and hypertrophy of the ankle joint's synovial lining can occur due to various causes. Chronic pain and degenerative changes may be due to synovitis causing clinical manifestations through traction on the joint capsule. The failure of conservative treatment for at least six months indicates arthroscopic debridement, which can provide significant pain relief without the morbidity of extensive surgical exposures. This study was therefore conducted to establish the functional results of arthroscopic debridement of the ankle joint in synovitis. Fifteen patients with chronic ankle pain who had not responded to conservative treatment for approximately six months were included in the study. Arthroscopic debridement was performed using a shaver blade, followed by a postoperative ankle physiotherapy regimen. Patients were assessed preoperatively and postoperatively using the AOFAS, FADI, and VAS scores, with a mean follow-up period of 26 months. There was a significant improvement in the final clinical outcomes of the patients. The post-operative VAS score improved to 2.20±0.56 (2-4) (p-value=0.001), the AOFAS score was 86±8.25 (65-98) (p-value-0.001), and the FADI Score was 86.93±7.35(70-96) (p-value=0.001). Thirteen patients (86.67%) achieved outstanding or good results, while two had fair results, according to Meislin's criterion. One patient reported a superficial wound infection, which subsided with antibiotic therapy. The study findings indicate that arthroscopic ankle debridement is an efficient method to treat persistent ankle discomfort induced by synovitis, and it has a low postsurgical complications rate, quicker recovery, and less joint stiffness.

Orthopaedic problems in the blind.

Background: Blindness is a common problem in every society and country. The problem ranges from complete blindness to partially sighted in the affected population. India has close to 12 million visually impaired people. Orthopaedic problems are not uncommon in blind. Orthopaedic Surgeons though had been aware of the postural and gait abnormalities in blind but very few published studies have systematically focused on the effect of blindness on the development of posture and gait. Methods: Case Control study done for the orthopaedic evaluation of the blind and partially sighted individuals. The study population included 242 students of Ahmadi School for the Blind, Aligarh Muslim University, Aligarh (India), as the cases and another matched set of 250 non-blind children. All the children were assessed for the orthopaedic problems like degree of ligamentous laxity, spinal alignment, foot morphology and alignment of hips, knees and ankles. Standing posture and gait were also examined and recorded. Ligamentous laxity was assessed according to the method adopted by Beighton et al.10 Chi-square test was applied using IBM SPSS 23.0. Results: 139 children (57.4 %) were found to have laxity of the ligaments. 72 children (29.7 %) had spine deformities, out of which kyphosis was present in 34 (47.2 %), scoliosis in 23 (31.9 %), lordosis in 13 (18.0 %), and meningomyelocele in 2 (2.9 %) children. 119 children (49.1 %) had foot deformities. 37 children (15.2 %) had knee deformity. 22 children (9.0 %) showed evidence of cerebral palsy. 216 children (89.2 %) had varying degrees of postural abnormalities. The data was statistically significant when compared with the control group (P < 0.05). Conclusion: Blindness causes a wide range of complicated sensory and motor problems that frequently forces people into isolation. Blind rehabilitation requires an interdisciplinary approach. Orthopaedic problems are quite common in blind individuals and should be dealt separately.

Haemophilic arthropathy of the knee: a surgeon's nightmare.

Surgical management of knee synovitis secondary to mild haemophilia, without any significant previous medical history and an adverse family history of haematological disorders, is arduous. Due to its rare occurrence, the diagnosis is often delayed or sometimes missed, leading to the grave and often lethal consequences in intraoperative and postoperative periods. Hardly isolated knee arthropathy due to mild haemophilia has been reported in the available literature. In this report, we present the management of a case of a 16-year-old male with isolated knee synovitis with undiagnosed mild haemophilia, who came to us with the first episode of knee bleeding. We elucidate the signs and symptoms, investigations, surgical management, and difficulties faced, especially during the postoperative period. This case report is presented to enhance awareness of the existence of this disorder and its management to prevent postoperative complications.

Pantalar dislocation: a rare presentation with review of treatment methods.

Pantalar dislocation means the simultaneous dislocation of the talocalcaneal, talonavicular, and tibiotalar joint. It is a rare injury comprising only 3.4% of major talar injuries. Treatment of closed Pantalar dislocation is controversial. However, the aim should be to attain a stable anatomic reduction of the Talus in the ankle joint. To prevent further damage to the skin and neurovascular structures, closed reduction of these dislocations should be performed as soon as possible. We report a case of Pantalar dislocation where we tried to reduce the talus both by closed and open methods but it was not possible to reduce the dislocation until the talonavicular joint was reduced first. Intending to improve the clinical knowledge of Pantalar dislocation, we want to convey our clinical experience and results from this rare dislocation.

A comparative study of Proximal Femoral Nail (PFN) versus Dynamic Condylar Screw (DCS) in management of unstable trochanteric fractures.

Trochanteric hip fractures have become very common with 35-40% of these fractures being unstable. Trochanteric fractures, especially unstable ones are associated with high rates of mortality and morbidity and thus remain an inordinate challenge for surgeon to treat these fractures with proper choice of implant. Aim of the study was to compare the proximal femoral nail and dynamic condylar screw in the management of unstable trochanteric fractures. Our study was a prospective comparative study which included 26 patients with fresh (≤3 weeks old) unstable trochanteric fractures AO 31A2 and AO 31A3, with age ≥18 years of both sexes. Eleven patients in DCS and fifteen patients in PFN were included. Harris hip score was used to compare functional outcomes. Average age of patients in DCS group was 59.82±11.59 years and PFN was 54.2±16.22 years. AO 31A2 fracture pattern (63.64%) was more common than AO 31A3 in DCS group and AO 31A3 fracture pattern (60.00%) was more common than AO 31A2 in PFN group. Mean operative time for DCS was 96.36±15.51 minutes and for PFN it was 79.67±12.02 minutes with P-value of 0.003. Two patients in DCS group and 1 patient in PFN group were lost to follow up. Two patients in DCS group and 1 patient in PFN group died. Seven out of 11 (63.64%) patients in DCS group and 13 out of 15 (86.60%) patients in PFN group were available for final follow up. Union seen in 2 (28.57%) patients with DCS and 12 (92.31%) patients fixed with PFN with P-value of 0.007. Mean HHS of 62.29±24.26 in DCS and 86.92±11.65 in PFN with P-value of 0.037. Patients with combined excellent and good HHS in DCS group and PFN group were 2 (28.57%) and 11 (84.62%) respectively. Non-union was seen in 5 (71.43%) patients fixed with DCS and 1 (7.69%) patient fixed with PFN. Implant failure was seen in 3 (42.86%) patients in DCS group in which barrel plate was broken in 2 (28.57%) patients and lag screw cut out through femoral head in 1 (14.29%) patient and 1 (7.69%) patient in PFN group due to varus collapse and complete backout of screw. Varus collapse was seen in 3 (42.86%) patients in DCS group and 4 (30.76%) patients in PFN group. Proximal femoral nail is better implant as compared to dynamic condylar screw which was statistically significant in terms of lesser operative time, higher union rate and better functional outcome. So PFN is a better implant choice for unstable trochanteric fractures when compared with DCS.

Does an Adjustable-Loop Device Loosen following ACL Reconstruction with a Hamstring Graft? A Retrospective Study with a Follow-Up of Two Years.

Arthroscopic anatomic anterior cruciate ligament reconstruction (ACLR) is the gold standard treatment for an ACL tear and requires the use of fixed or adjustable-loop devices to fix a femoral-side graft. Although the adjustable mechanism is designed to provide one-way tensioning, there is a concern that the adjustable loop will loosen and lengthen during cyclic loads, creating graft laxity. The present paper is a retrospective study of patients who underwent ACLR with the fixation of a hamstring graft with an adjustable loop on the femoral side from November 2016 to October 2018. The knee's functional outcome was evaluated using an International Knee Documentation Committee (IKDC) score, Lysholm score, Lachman test, and pivot shift test. The patients were assessed preoperatively and finally postoperatively after two years of surgery. Thirty-two patients were analyzed. Significant improvement was obtained in the final clinical outcome of the patients. Twenty-seven patients (84.4%) were Lachman negative, and twenty-eight patients (87.5%) were pivot shift test negative, the mean Lysholm score was 96.91, and the IKDC score was 91.47 (p < 0.001). There was no infection, graft failure, or flexion restriction. Arthroscopic ACLR with an adjustable-loop suspensory device is a successful fixation method for femoral-side graft fixation and offers a similar functional outcome as with fixed-loop devices.

Single-stage versus two-stage reconstruction in chronic multi ligament knee injury.

BACKGROUND: Multi ligament knee injury (MLKI) refers to the disruption of at least 2 of the 4 major knee ligaments. These injuries are managed in single and two-stage surgeries however, treatment guidelines for best practice are unsettled. There is no study in the literature that compares single and two-stage surgery for the management of chronic multiligament knee injury. Therefore, the aim of this study was to compare the functional outcome between single-stage and two-stage surgical fixation in chronic multi-ligament knee injury. METHODS: Twenty seven patients with chronic MLKI with at least 2 years of follow up were included. Fourteen patients underwent reconstruction of torn ligaments in a single-stage operation (Group I) and 13 patients underwent reconstruction of torn ligaments in two stages (Group II). Assessment of clinical outcome was done with IKDC knee score, TEGNER LYSHOLM knee score, range of movement and laxity tests (Anterior drawer test, Lachman, Posterior drawer test, pivot shift test, dial test, varus and valgus stress test). RESULTS: At final follow up, there was no significant difference in post-operative IKDC knee scores in group I and group II (84.7±7.1 and 81.4±8.4 respectively, p=0.3) and Lysholm scores (85.8±8.3 and 80.9±8.3 respectively, p=0.1), range of movement (133.2±5.7 and 131.5±6.6 respectively, p=0.5) and all the patients regained full extension. At the final follow up 12/14 patients (85.7%) in group I and 11/13 patients (84.6%) in group II had a negative/grade 1 anterior drawer test (p=0.6), 14/14 (100%) in group I and 13/13 (100%) patients had negative/grade 1 lachman test (p=0.6), 13/14 patients (92.8%) in group I and 13/13 patients (100%) patients in group II had negative/grade 1 pivot shift test (p=0.4), 9/10 patients (90%) in group I and 12/13 patients (92.3%) in group II had negative/grade 1 posterior drawer (p=0.6), 6/6 patients (100%) in group I and 6/7 patients (85.7%) in group II had negative/grade 1 dial test (p=0.3), 5/6 patients (83.3%) in group I and 5/7 patients (71.4%) in group II had negative/grade 1 varus stress test (p=0.4), 6/7 patients (85.7%) in group I and 7/7 patients (100%) in group II had negative/grade 1 valgus stress test (p=0.1). CONCLUSION: Chronic MLKI managed by single stage and two stage reconstruction provides similar functional outcomes. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

A prospective randomized study of arthroscopic ACL reconstruction with adjustable- versus fixed-loop device for femoral side fixation.

PURPOSE: Suspensory devices are extensively used in the management of anterior cruciate ligament (ACL) tear. They include fixed- and adjustable-loop devices. There are only a few studies comparing the efficacy of these two devices in the available literature. Therefore, the aim of this study is to compare clinical outcomes between the adjustable-loop device (group I) and fixed-loop device (group II). MATERIALS AND METHODS: This was a prospective randomized study. Both groups were equivalent in demographic, preoperative, and intraoperative variables. Twenty-three patients underwent femoral side graft fixation with adjustable-loop and 20 with fixed-loop devices. Four patients were lost to follow-up. Assessment of clinical outcome was done with International Knee Documentation Committee (IKDC) score, Lysholm score, and knee stability tests (Lachman test and pivot shift test). Patient evaluation was performed preoperatively and finally postoperatively 2 years after surgery. RESULTS: Postoperative IKDC scores of group I and II were 91.9 ± 3.6 and 91.5 ± 3.6, respectively, and Lysholm scores were 91.0 ± 3.6 and 91.4 ± 3.5, respectively, after 2 years; however, the difference in the outcomes was statistically insignificant (p > 0.05). Twenty patients (87%) in group I and 17 patients (85%) in group II had a negative Lachman test (p = 0.8). Twenty-two patients (95.7%) in group I and 19 patients (95%) in group II had a negative pivot shift test (p = 0.9). CONCLUSION: ACL reconstruction with fixed- and adjustable-loop suspensory devices for graft fixation gives equivalent and satisfactory clinical results. LEVEL OF EVIDENCE: 1.

Prediction of peroneus longus graft diameter for anterior cruciate ligament reconstruction by inframalleolar harvest and from anthropometric data.

BACKGROUND: The literature is gradually drifting towards a graft of larger diameter for successful ACL reconstruction. There is no published literature regarding the anthropometric predictors for the diameter of the peroneus longus tendon (PLT) graft obtained in ACL reconstruction through the inframalleolar approach. METHODS: Fifty-two patients were finally evaluated for anthropometric parameters to predict quadrupled PLT graft diameter in ACL reconstruction using the inframalleolar technique. Intraoperative quadrupled PLT graft diameter was correlated to the patient's anthropometric data such as age, height, weight, duration of injury, and BMI. We used regression analysis in a stepwise manner to ascertain anthropometric indices associated with the graft diameter. RESULTS: This study included 46 males and six females. Mean age was 28.2 ± 7.4 years, mean height was 172.7 ± 2.8 cm, mean weight was 75.6 ± 3.4 kg, mean BMI was 25.3 ± 0.9 kg/m2, mean duration of injury was 9.2 ± 3.9 months, and mean graft diameter was 9.3 ± 0.4 mm. Positive correlation with graft diameter was found only with height (r = 0.6, P < 0.01) and weight (r = 0.4, P < 0.01). On analysing through linear regression, height and weight had significant association with graft diameter, and we formulated the following prediction equation: PLT graft diameter (mm) = 0.083 × height (cm) + 0.011 × weight (kg) -5.854. CONCLUSION: Patients' characteristics, including height and weight, have a significant correlation with quadrupled PLT graft diameter and the average diameter of graft is > 9 mm through this approach.

Challenges in management of benign bone tumours complicated by pathological fracture in paediatric population.

BACKGROUND: Optimum treatment of pathological fractures following benign bone tumours in paediatric population is controversial. The usual difficulties encountered while dealing such cases is to establish a correct pre-operative diagnosis and to choose between conservative vs operative management. The aim of the work is to highlight the difficult aspects of diagnosis and management of pathological fractures following benign bone tumours in paediatric population. METHODS: All paediatric patients (<18 years) with pathological fractures following benign bone tumours were included. Pathological fractures due to infection, metabolic bone diseases and malignant bone tumours were excluded. Initial pre-operative diagnosis was based on clinico-radiological characteristics of the tumour and FNAC/needle biopsy, while final diagnosis was confirmed with post-operative histology. Primary outcome measure was determination of any disparity between pre-operative diagnosis and final post-operative histological diagnosis and the need of a separate open biopsy procedure for establishing the exact nature of lesion. Secondary outcome measures were determination of complications following surgery, functional grade and any recurrence at latest follow-up at 3 years. RESULTS: Out of 13 patients enrolled for the study, twelve patients met the inclusion criteria. Female to male quotient was 3:1, with average age of 12.17 years. We were able to make correct pre-operative diagnosis in 10 patients (83.3%) with systematic clinico-radiological analysis and carefully performed FNAC/needle biopsy. Disparity between pre-operative and final post-operative diagnosis was seen in two patients. In one of these two patients, initial pre-operative diagnosis was fibrous dysplasia, which turned out to be ossifying fibroma on final post-operative biopsy. While the other patient required an open biopsy to establish the nature of underlying pathology, as the pre-op histological evaluation revealed equivocal nature of bone lesion. Secondary outcome measures showed superficial infection in one, coxa vara in one, limb length discrepancy in 2 and fibular graft donor site morbidity in two. None of the patient had developed recurrence. All patients had complete healing of the fracture and lesion. CONCLUSION: A thorough clinico-radiological analysis and carefully performed FNAC/needle biopsy can establish a correct pre-operative diagnosis in majority of patients with benign bone tumours complicated by pathological fracture. This approach will avoid preventable delay in the definitive treatment of such patients, and also preclude the need of a separate operation prior to definitive management. In sight of the findings of our study along with existing literature we propose for definitive treatment in straight-forward cases and pre-treatment biopsy in cases with inconclusive FNAC/needle biopsy results and lesions with suspicion of malignancy. Proper diagnostic evaluation and differentiation of benign pathological fractures from malignant counterparts followed by extended curettage or excision of lesion and biological reconstruction with or without osteosynthesis represents a feasible approach for managing such fractures.

Technical difficulties and mechanical failure of distal femoral locking compression plate (DFLCP) in management of unstable distal femoral fractures.

Objective of the paper is to portray the technical difficulties and mechanical failure of Distal Femoral Locking Compression Plate in the management of unstable distal femoral fractures. The primary outcome measure was defined as revision surgery due to implant failure with subsequent non-union. Secondary outcome measures were mal-union, delayed union, peri-implant fracture and infection. Functional outcome were evaluated using Schatzker & Lambert criteria. Thirty nine patients were available for final follow up. The rate of revision surgery as primary outcome measure was 7.69%. Mal-union was seen in 5.1%, delayed union in 7.69%, superficial infection in 10.25% and deep infection in 5.1% patients. All except three fractures united following index surgery. Functional outcome as per the Schatzker & Lambert Criteria was excellent in 20.5%, good in 48.7%, fair in 18% and failure in 12.8%. In sight of the findings of our study along with existing literature we propose for creating a fixation construct that is conducive for fracture healing by following principles of locking compression plating and augmenting stability by medial column reconstruction.

Role of Whole-Spine Screening Magnetic Resonance Imaging Using Short Tau Inversion Recovery or Fat-Suppressed T2 Fast Spin Echo Sequences for Detecting Noncontiguous Multiple-Level Spinal Tuberculosis.

STUDY DESIGN: Retrospective review. PURPOSE: The purpose of the present study was to evaluate the role of whole-spine screening using short tau inversion recovery (STIR) or fat-suppressed T2W fast spin echo (FSE) sequences in patients with spinal tuberculosis (TB). OVERVIEW OF LITERATURE: The identification of noncontiguous multiple-level spinal tuberculosis (NMLST), symptomatic or not, is important because of its management implications. Most centers do not perform routine whole-spine magnetic resonance imaging (MRI), and the reported incidence of NMLST varies from 1.1% to 74.1%. METHODS: We completed a retrospective review of clinical and radiographic data of 365 patients with spinal TB who presented at Jawaharlal Nehru Medical College, Aligarh over 5 years. The final analysis included 187 patients who full filled the inclusion criteria, consisting of availability of whole-spine MRI and confirmation of vertebral TB. Diagnosis of NMLST was considered when other vertebral lesions were identified in addition to the primary vertebral disease, with the lesions separated by at least one normal spinal segment. The primary site was defined as the site for which the patient had been referred for MRI. RESULTS: NMLST was identified in 47 of 187 patients investigated using whole-spine MRI. The incidence was 25.1%, which was higher than that in earlier reports where whole-spine MRI was not routinely performed. The lumbar spine was involved in 37 patients, thoracic spine in 25, cervical spine in 16, and sacrum in five patients. Combined lumbar spine and thoracic spine involvement was observed in 19 patients. Thirteen patients had lumbar and cervical spine involvement, nine had thoracic and cervical spine involvement, four had combined lumbar and sacral spine involvement, and the remaining two had thoracic and sacral spine involvement. CONCLUSIONS: Tubercular spondylitis may affect the spine at multiple noncontiguous sites with the majority of additional affected sites remaining asymptomatic. Routine whole-spine MRI using all recommended sequences is not cost-effective and hence not feasible. Therefore, we recommend whole-spine screening using STIR or fat-suppressed T2W FSE sequences in all patients with suspected spinal TB. This screening is cost-effective compared with full-protocol MRI and detects additional cases of NMLST over conventional practice.