Early Clinical Outcomes of a New Posteriorly Stabilized Total Knee Arthroplasty Prosthesis: Comparisons with Two Established Prostheses.

Purpose: We sought to determine whether early clinical performance of new posterior stabilized (PS) knee system, the Vega-PS (Aesculap), is better than that of two established total knee arthroplasty (TKA) prostheses, the E.motion-PS (Aesculap) and the Genesis II (Smith & Nephew) in terms of functional outcomes, patient satisfaction, and incidence of adverse events. Materials and Methods: We compared the clinical outcomes of 206 consecutive TKAs using Vega-PS with those of 205 TKAs using E.motion-PS and 216 TKAs using Genesis II at 2 years of follow-up. Results: Overall, the knees with the Vega-PS had better functional outcome scores than the knees with the E.motion-PS, but had similar outcome scores to the knees with the Genesis II, as evident from the American Knee Society knee score (94.2 vs. 92.5 vs. 93.2), Western Ontario McMaster Universities Osteoarthritis (WOMAC) stiffness index (1.8 vs. 2.3 vs. 2.0), WOMAC function index (11.8 vs. 16.8 vs. 18.5), Short Form 36 (SF-36) physical component summary score (41.9 vs. 39.3 vs. 41.6), and SF-36 mental component summary score (50.0 vs. 45.8 vs. 46.9). Patient satisfaction was higher in the Vega-PS and Genesis II groups than the E.motion-PS group. No notable group differences were found in terms of the incidence of adverse events. Conclusions: The Vega-PS, a newly developed PS fixed bearing prosthesis, had comparable or superior clinical performance in comparison with the two established fixed or mobile bearing PS prostheses.

Glomus tumours of the hand: Review of literature.

Glomus tumours are rare benign vascular neoplasms commonly found in the hand particularly in subungual region. Though, its aetiology remains largely unknown, several hypotheses have been made to explain the etiopathogenesis and cause of pain. These tumours usually present as a bluish or pinkish red discolouration of the nail plate with classical triad of localised tenderness, severe pain, and cold sensitivity. Nevertheless, differential diagnosis of other painful tumours, such as leiomyoma, eccrine spiradenoma, haemangioma, neuroma, osteochondroma, or mucous cyst should always be kept in mind while evaluating a patient with severe pain in the tip of the finger. In addition to the different clinical tests including Love's pin test, Hildreth's test, and trans-illumination test, imaging studies such as magnetic resonance imaging (MRI), ultrasonography, and radiography are often helpful in the diagnosis. Complete surgical excision is a must to get complete relief from the symptoms and to avoid recurrence. Several approaches have been described in the literature. Different surgeons may have different choices and may prefer one approach over the other depending on the anatomical location of the tumours. The purpose of this article is to review the important aspects of glomus tumours in hand concerning their aetiology, clinical presentation, diagnosis, management, and recurrence.

Arthroscopic anatomic double bundle anterior cruciate ligament reconstruction: Our experience with follow-up of 4 years.

BACKGROUND: Double bundle (DB) anterior cruciate ligament (ACL) reconstruction has been proposed to recreate the natural anatomy of ACL. Reconstruction of the anatomy of both the bundles of ACL has been thought to be able to restore the rotational stability of the knee joint. Nevertheless, it remains unclear whether DB reconstruction has better functional outcome than single bundle (SB) ACL reconstruction. PURPOSE: To evaluate the clinical outcomes, patient satisfaction and manual laxity tests of knee in patients treated with DB ACL reconstruction in Indian population. METHODS: We prospectively followed 25 patients with an isolated ACL injury operated for DB ACL reconstruction after applying the inclusion and exclusion criteria. Patients were evaluated pre-operatively and in the post-operative period at regular intervals with the minimum follow up of 4 years. Clinical stability was assessed by anterior drawer test, Lachman test and pivot shift test. Functional outcome was assessed by IKDC, Lysholm and Modified Cincinnati scores. RESULTS: At the end of 4 years, functional outcome in terms of all subjective scores was satisfactory. Graded stability results of the Lachman, Anterior drawer and pivot shift tests were almost near to that in normal knee. No complication occurred post-operatively. CONCLUSION: Anatomical DB ACL reconstruction seems to offer satisfactory results in terms of subjective scores and stability tests to patients with ACL tear. It has been found to be associated with no obvious complications and no failures. However a larger patient pool is desired for conclusive results.

Can Serum Albumin Level and Total Lymphocyte Count be Surrogates for Malnutrition to Predict Wound Complications After Total Knee Arthroplasty?

BACKGROUND: Although the serum albumin level and total lymphocyte count (TLC) have been reported as valid and reliable markers for defining malnutrition, their cutoff levels and predictive values for wound complications in patients undergoing total knee arthroplasty (TKA) remain questionable. METHODS: A total of 3169 TKAs performed between April 2003 and December 2013 were retrospectively reviewed. We determined the prevalence of malnutrition on applying different definitions, with various cutoff values of serum albumin and TLC and analyzed the variations in outcome. The differences between groups with and without malnutrition in terms of functional outcome and complications were determined using Student's t test and analysis of variance. Multivariate logistic regression analysis was conducted to identify the independent risk factors. RESULTS: Among all the patients (N = 3169), the serum albumin level and TLC varied widely, with means of 4.1 g/dL and 2189 cells/mm(3), respectively. The prevalence of malnutrition (21%) as per the conventional definition (serum albumin level <3.5 g/dL or a serum TLC <1500 cells/mm(3)) dropped to only 1.6% when malnutrition was defined as serum albumin <3.5 g/dL "and" TLC <1500/mm(3), indicating a very small overlap between the 2 markers. No differences were observed between 2 groups in functional outcomes and incidence of wound complications. CONCLUSION: Our findings call into question the values of serum albumin level and TLC as a surrogate of malnutrition for predicting wound complications after TKA.

A prospective comparative study of clinical and functional outcomes between anatomic double bundle and single bundle hamstring grafts for arthroscopic anterior cruciate ligament reconstruction.

BACKGROUND: Despite a number of studies comparing postoperative stability and function after anatomic single bundle and double bundle anterior cruciate ligament reconstruction, it remains unclear whether double bundle reconstruction has better functional outcome than single bundle anterior cruciate ligament reconstruction. PURPOSE: To compare the subjective functional outcome as well as clinical stability in patients treated with either anatomic single bundle or anatomic double bundle anterior cruciate ligament (ACL) reconstruction. We hypothesized that there would be no difference in the postoperative functional outcome and clinical stability between anatomical double bundle anterior cruciate ligament reconstructions when compared to single bundle anterior cruciate ligament reconstructions. METHODS: We prospectively followed 40 patients out of which, 20 patients were operated for anatomic single bundle ACL reconstruction and other 20 patients underwent anatomic double bundle ACL reconstruction. Patient evaluation using the laxity tests and outcome scales was done preoperatively and at 12, 24 and 48 months after the surgery. Clinical stability was assessed by Lachman test, Pivot shift test and Delhi active test. Functional outcome was assessed by International Knee Documentation Committee (IKDC), Lysholm and Modified Cincinnati scores. Patients in both groups were evaluated at regular intervals for a minimum period of 48 months (mean 51 months, range 48-56 months). RESULTS: For all subjective scores, double bundle group patients reported statistically significant higher scores compared to single bundle group patients. Graded stability results of the Lachman, and Pivot shift tests were significantly higher in the anatomically reconstructed double bundle patient group. CONCLUSION: We suggest that functional outcome and clinical stability may be better with anatomical double bundle anterior cruciate ligament reconstruction as compared to anatomical single bundle anterior cruciate ligament reconstruction.

Functional Outcomes of a New Mobile-Bearing Ultra-Congruent TKA System: Comparison With the Posterior Stabilized System.

We determined whether a new mobile-bearing ultra-congruent (UC) TKA system provides better functional outcomes than an established posterior-stabilized (PS) prosthesis. The functional outcomes (motion arc, AKS scores, WOMAC Index, and SForm-36 scores evaluated at 1 and 2 years postoperatively), satisfaction and incidences of adverse events were compared between the knees implanted with mobile-bearing UC prosthesis (n=103) and the mobile-bearing PS prosthesis (n=99). At 2 years, mobile-bearing UC TKAs showed similar functional outcomes and satisfaction, but smaller motion arc compared to mobile-bearing PS TKAs (126° vs. 131°). There were no differences in the incidence of adverse events. Mobile-bearing UC prosthesis can be considered a safe and viable alternative to the PS design, with an expectation of smaller postoperative maximum flexion.

Prevalence and Risk Factors of Spine, Shoulder, Hand, Hip, and Knee Osteoarthritis in Community-dwelling Koreans Older Than Age 65 Years.

BACKGROUND: Osteoarthritis (OA) is common and disabling among older patients around the world. Data exploring the prevalence and risk factors of OA are of paramount importance in establishing healthcare policies. However, few studies have evaluated these topics among Asian populations. QUESTIONS/PURPOSES: This study was conducted to determine the prevalence and risk factors of radiographic OA in the spine, shoulder, hand, hip, and knee in Koreans older than age 65 years. METHODS: A simple random sample (N = 1118) was drawn from a roster of elderly individuals older than age 65 years in Seongnam. Of the 1118 invited subjects, 696 (males = 298, females = 398) participated in this study (a response rate of 62%). The mean age of respondents was 72 ± 5 years (range, 65-91 years). Radiographs of the lumbar spine, shoulder, hand, hip, and knee were taken and afterward evaluated for radiographic OA. The Kellgren-Lawrence grading system was used for all mentioned joints, and radiographic OA was defined as Grade 2 changes or higher. The association of sex, aging, and obesity with OA in each of the mentioned joints was determined with the help of multivariate logistic regression. RESULTS: The highest prevalence of radiographic OA was seen in the spine (number of subjects with OA/number of whole population = 462 of 696 [66%]) followed by the hand (415 of 692 [60%]), knee (265 of 696 [38%]), shoulder (36 of 696 [5%]), and hip (15 of 686 [2%]). Female sex was associated with knee OA (odds ratio [OR], 5.7; 95% confidence interval [CI], 3.9-8.4; p < 0.001) and hand OA (OR, 2.3; 95% CI, 1.6-3.1; p < 0.001), and male sex was associated with spine OA (OR, 0.7; 95% CI, 0.5-1.0; p = 0.025). Aging was associated with radiographic OA in the spine, knee, and hand (OR per 5-year increments, 1.3 [95% CI, 1.1-1.6; p = 0.001], 1.6 [95% CI, 1.4-1.9; p < 0.001], and 1.4 [95% CI, 1.2-1.7; p < 0.001]), respectively) but not associated with OA in the hip and shoulder. Obesity was associated with knee OA (OR, 3.4; 95% CI, 2.4-5.0; p < 0.001) and spine OA (OR, 1.5; 95% CI, 1.1-2.2; p = 0.014) but not with OA in other joints. CONCLUSIONS: OA of the spine, hand, and knee is likely to become a major public health problem rather than shoulder and hip OA in Korea. Associations of demographic factors with radiographic OA differed among each joint, and that would be valuable information to assess the role and influence of risk factors of OA in various joints. LEVEL OF EVIDENCE: Level III, prognostic study.

Isolated spontaneous primary tubercular erector spinae abscess: a case report and review of literature.

Isolated spontaneous primary tubercular erector spinae abscess in an immunocompetent patient is very rare. Here, we report such a case of 21-year-old female, which was successfully managed with timely diagnosis and intervention. Isolated primary tubercular abscess of erector spinae is a rare differential diagnosis of low back pain; however, it must be suspected in an endemic region for tuberculosis, especially when raised erythrocytic sedimentation rate and C-reactive protein are present. Excision along with anti tubercular therapy proved to be a successful strategy in our patient.

On-table reconstruction and fixation of Mason type III radial head fractures.

PURPOSE: To evaluate the functional and radiological outcome of comminuted radial head fractures, which were not amenable for classical open reduction with internal fixation, treated by on-table reconstruction and fixation using low profile plates. METHODS: We reviewed 6 patients of Mason type III radial head fractures treated by on-table reconstruction technique between 2011 and 2013. There were 5 men and 1 woman with a mean age of 35 years (range 25-46 years). All surgeries were carried out at our tertiary care level 1 trauma centre within a mean of 3 days (range 1-8 days) from date of injury using on-table reconstruction technique. The functional outcome was measured using elbow functional rating index described by Broberg and Morrey and the patient-based Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure. RESULTS: The mean follow-up period was 25 months. The average elbow flexion was 135°(range 125°-140°) and theaverage flexion contracture was 5°(range 0-10°). The average supination and pronation was 75°(range 70°-80°) and 70°(range 65°-82°) respectively. According to Broberg and Morrey scoring system, the average score was 90 points (range 75-100). The mean DASH score was 2.49 points. CONCLUSION: On-table reconstruction and fixation of comminuted radial head fractures using low profile plates is a reasonable option. The reconstructed radial head acts as spacer and provides reasonably good results and no surgical intervention is required for asymptomatic nonunion of these fractures regardless of the radiological findings.

Transient patellar dislocation resulting in simultaneous osteochondral fractures of patella and lateral femoral condyle - a case report.

Transient Patellar dislocations are commonly associated with bony contusions or osteochondral fractures involving the medial facet of patella or lateral femoral condyle. Simultaneous osteochondral fractures are rare and have not been reported in the adult. The authors report a case of combined osteochondral fracture of patella and lateral femoral condyle following acute patellar dislocation in an adult, which was misdiagnosed as meniscal injury. Both the osteochondral fracture fragments were rigidly fixed with headless compression screws and repair of the medial retinaculum was done. At latest follow up after two years, patient had regained full range of motion with no further episodes of patellar dislocation. The rarity of this combination of injury along with difficulty in interpreting radiographs makes this case interesting.

Surgical treatment of proximal humerus fractures using PHILOS plate.

OBJECTIVE: To evaluate functional outcome and complications of open reduction and internal fixation with proximal humeral internal locking system (PHILOS) plate for proximal humerus fractures. METHODS: We reviewed 51 patients who underwent open reduction and internal fixation with PHILOS plate between the years 2007 to 2012. There were 35 men and 16 women with a mean age of 38 years (range 24-68). There were 41 patients in the age group of <60 years and 10 patients in the age group of >60 years. According to Neer classification system, 8, 15 and 23 patients had 2-part, 3-part, and 4-part fractures, respectively and 5 patients had 4-part fracture dislocation. All surgeries were carried out at our tertiary care trauma centre. Functional evaluation of the shoulder at final follow-up was done using Constant-Murley score. RESULTS: The mean follow-up period was 30 months (range 12-44 months). Two patients were lost to follow-up. Of the remaining 49 patients, all fractures were united clinically and radiologically. The mean time for radiological union was 12 weeks (range 8-20 weeks). At the final follow-up the mean Constant-Murley score was 79 (range 50-100). The results were excellent in 25 patients, good in 13 patients, fair in 6 patients and poor in 5 patients. During the follow-up, four cases of varus malunion, one case of subacromial impingement, one case of deep infection, one case of intraarticular screw penetration and one case of failure of fixation were noted. No cases of avascular necrosis, hardware failure, locking screw loosening or nonunion were noted. CONCLUSION: PHILOS provides stable fixation in proximal humerus fractures. To prevent potential complications like avascular necrosis, meticulous surgical dissection to preserve vascularity of humeral head is necessary.

Pigmented villonodular synovitis of 1st metatarsophalangeal joint: a case report and literature review.

Pigmented villonodular synovitis is a common disease entity particularly in the knee joint but its incidence in the foot is quite rare. A case of first metatarsophalangeal (MTP) joint pigmented villonodular synovitis (PVNS), presented to us with recurrence of symptoms after surgical excision done outside our institute. After histological confirmation of recurrence of the disease, repeat open surgical excision was performed. After being asymptomatic for two months she presented to us with recurrence of symptoms for which hyperkeratotic plaque at the ventral aspect of the first MTP joint was found to be responsible on physical examination. It was treated surgically by pairing it and now patient is symptom free for last 1 year. It signifies the importance of the histopathology in the diagnosis and recurrence of the PVNS and thorough physical examination in the management of the foot pathologies.

Intraarticular osteochondroma of the knee.

Osteochondromas are usually extra articular and grow away from the joint towards the diaphysis. Intraarticular osteochondromas are very rare and often misdiagnosed. We report a case of 16-year-old boy who presented with pain and clicking sound in the right knee for last 6 months. On examination, click was felt at the terminal flexion of the knee. The lateral radiograph of the right knee showed a radio opaque shadow at the posterior aspect of the distal end of femur, which was further evaluated with an MRI. Arthroscopy showed a hard lesion arising from the roof of the intercondylar notch of femur. It was excised arthroscopically. Histopathology revealed it to be an osteochondroma. Thus, intraarticular osteochondroma of the knee can be considered as a rare cause of pain in young patients.

Multifocal metachronous giant cell tumour in bilateral upper limb: a rare case presentation.

Giant cell tumour (GCT) of bone is a benign but locally aggressive tumour and accounts for 20 % of all benign bone tumours and 5 % of all bone tumours. Multicentric GCT of bone is a rare entity and has increased prevalence of involvement of the small bones of hands and feet in multicentric GCT. The clinical behaviour in multicentric GCTs tends to be aggressive as in recurrent GCTs. En-bloc resection remains the most successful surgical technique for treating both multicentric and solitary lesions. We report a 14-year-old female patient presenting with metachronous benign GCT located at the right proximal humerus and subsequent lesions in left hand and left proximal humerus. The case was treated with multimodality therapy including en-bloc resection along with bisphosphonate therapy over a period of 5 years.

Primary repair of capsuloligamentous structures of trapeziometacarpal joint: A preliminary study.

BACKGROUND: Isolated trapezio-metacarpal joint dislocation is uncommon and challenging since controversy still exists regarding its management. DESCRIPTION: We present a short case series in which direct repair of trapezio-metacarpal ligaments was done in three patients who had isolated, unstable dislocation of the thumb carpometacarpal joint. All of them were engaged in tasks where no compromise in hand functions and grip strength was affordable. The dislocation was addressed primarily by repair of volar oblique and dorsoradial ligaments with suture anchors. The joint was immobilised in a cast for 4 weeks followed by gradual mobilisation. RESULTS: At an average follow up of 15 months, all the three patients have no restriction in the range of motion. There are no symptoms and signs of instability. In two patients, there is no pain at all; while one patient has occasional pain which is mild and does not interfere with the hand function. Radiographic examination showed normal joint alignment and no signs of subluxation or early osteoarthritis. CONCLUSION: Repair of the capsuloligamentous complex with suture anchors may be considered as a treatment option in unstable trapezio-metacarpal joint dislocations in high demand patients.

Skeletal tuberculosis following proximal tibia fracture.

Over the past several years, there has been a rise in incidence of tuberculosis in both developing and developed countries. Tuberculosis complicating a fracture is uncommon. In this article, we report the case of a 10-year-old patient with a proximal tibia fracture who developed discharging wound over the fracture site after 2 weeks of initial trauma. The fracture was showing no signs of healing. A diagnosis of tuberculosis of proximal tibia was made on the basis of polymerase chain reaction and histology. After antituberculous treatment was started, the sinus healed and the fracture united. To the best of our knowledge, such a presentation has not been documented.