Role of placental membrane in ACL graft healing - A series of 18 patients.

Introduction: ACL injuries are common and the standard treatment remains to be ACL reconstruction. Controversy still remains around graft ligamentisation and various methods have been experimented to augment this process. In this series we discuss the outcome of using dehydrated umbilical cord derived membrane in ACL reconstruction. Material and method: A prospective Level IV analysis of outcome in 30 consecutive patients of complete isolated ACL tear presenting to us between May 2022 to September 2022 was done. There was no age or sex restriction. Revision cases were excluded from this series. ACL reconstruction was done using standard all inside technique using the ipsilateral semitendinosus graft which was wrapped with dehydrated umbilical cord derived membrane (5*3 cm2) after soaking in normal saline (Cord Thick - Life Cell; LifeCell international private limited, Chennai, Tamil Nadu, India) and secured with Monocryl 3-0 sutures in a continuous manner. Results: 18 patients completed the one year follow up and were analysed for final results. Eleven of the patients followed up were females and seven males, with an average age of 30.3 years.The average VAS score at 6 weeks was 2.2. The mean KOOS score at the follow up visits were 72.3, 82.3, 90.7, 95.8. The mean SANE score reported at 6 weeks, 3 months, 6 months and 1 year were 68.8, 80, 87.5, 95.1.The follow up MRI's confirmed good ligamentisation of the graft even as early as 6 weeks with minimal fluid in the tunnel. Conclusion: The use of dehydrated umbilical cord derived membrane augmentation to potentiate graft integration in ACL reconstruction seems promising and helps improve patient outcomes.

Anterior knee pain following BPTB graft harvest. Reality or overhyped.

INTRODUCTION: The patellar tendon graft has long been the gold standard for ACL reconstruction. Recently semitendinosus and gracilis tendons graft have been used increasingly. We hypothetise that the Bone-Patella Tendon-Bone graft is a good and economical graft for the Indian population with no adverse effects of anterior knee pain or patellar tendon shortening. We believe that the early squatting and cross-legged sitting causes early and constant stretching of the tendon in our patients. This is responsible for the lesser incidences of adverse effects in the Indian population. MATERIAL AND METHOD: In a retrospective study, the hospital database was scrutinized to shortlist patients who had undergone a bone-patella tendon-bone harvest for ACL or PCL reconstruction before 2013. Each patient was evaluated using the Lysholm score and the KOOS Score. VAS was also used, to evaluate for the amount of pain experienced by patients. The analysis of the quadriceps power along with the presence or absence of any extensor lag was made too. The modified Insall Salvati index was also calculated. RESULTS: Forty-seven patients were shortlisted of which 25 patients were followed up with an average follow up of 94.5 months. Although some patients did complain of occasional pain with the average VAS score of 1.45; on analyzing the data it was evident that all our patients had excellent quadriceps power (5/5) with no extensor lag. The mean Lysholm score was 95.55, while the mean KOOS score was 94.17. The mean Insall index of 1.05 showed no significant patella baja in any of our patients. CONCLUSION: It is ascertained that no significant retro-patellar pain or shortening of the patellar tendon occurs following a bone patella tendon bone harvest. The bone patella bone tendon graft is a suitable graft for ligament reconstruction with good functional outcome, and no significant adverse effect of patella baja or anterior knee pain in the Indian patients. LEVEL OF EVIDENCE: Level IV.

ACL femoral avulsion repair using suture pull-out technique: A case series of thirteen patients.

PURPOSE: Anterior cruciate ligament (ACL) repair was first described in the mid 1900's. However, due to poorly selected patients led to unsatisfactory early results. We aim to study the outcome of ACL repair in a carefully selected cohort. METHODS: Thirteen consecutive patients of acute Type 1 (proximal ACL avulsion) were treated with arthroscopic ACL repair using a suture pull out technique. At the latest follow-up the patients were evaluated for Lysholm score, KT-1000 measurement and clinical assessment for any laxity. RESULTS: At a mean follow-up of 31.3 months, none of the patients had any subjective laxity. The mean Lysholm score was 95 and instrumented laxity measurement did not reveal any significant laxity compared to the opposite knee. CONCLUSION: The proximal ACL avulsion has healing potential similar to proximal MCL injuries. Performing microfracture of the lateral wall of the notch optimizes the healing environment by negating the effects of the synovial fluid. Performing ACL repair in a carefully selected patient leads to good short term results and saves the patient of a reconstruction procedure, at least in the immediate future.

Suture Pullout Technique of Acute Anterior Cruciate Ligament Femoral Avulsion Repair.

It was in the early 1900s that anterior cruciate ligament (ACL) repair was first described with its resurgence in the mid-1900s. It however failed to gain popularity because of unsatisfactory early outcomes as a result of poorly selected patients. We describe a suture pullout technique of acute ACL repair in a carefully selected cohort of patients. Healing capabilities similar to that of the proximal medial collateral ligament have been shown in the proximal ACL avulsions. Adding microfracture of the lateral wall of the notch further enhances the healing environment by countering the synovial fluid environment. Acute ACL repair when performed in a carefully selected patient leads to good results and saves the patient of a reconstruction procedure.

Neglected epiphyseal injuries of the distal end of the radius with ulnar impaction: analysis of distal osteotomy of both bones using a dorsal midline approach.

BACKGROUND: To evaluate results of a technique for treating neglected epiphyseal injuries of the distal radius with ulnar impaction. MATERIALS AND METHODS: This retrospective study involved six cases (four males; two females), all of whom sustained the primary injury during childhood (range 9-12 years of age). All presented with wrist deformity and ulnar-sided wrist pain. They were managed with osteotomy of the distal radius, osteotomy and shortening of the ulna, harvesting the bone grafts, and distal radioulnar joint (DRUJ) reduction performed simultaneously through a dorsal midline approach. Mean follow-up was 30 months (range 24-36). RESULTS: Deformity correction and pain relief was observed in all patients. Flexion arc increased from an average of 60° to 102.5°, supination from an average of 31.67° to 67.50°, and pronation from an average of 30.83° to 61.67°. The mean preoperative DASH score was 87.5, which improved to 18.72 postoperatively. CONCLUSION: Neglected epiphyseal injuries of the distal radius are difficult to manage and many variations are described for handing each of the associated problems. Our technique provides an option for managing this injury with an easy surgical approach, single incision, and cost effectiveness. All the four components of the surgery, which include osteotomy of the distal radius, osteotomy of the ulna, harvesting the bone grafts, and DRUJ reduction were done through a single incision and in a single sitting. Level of evidence IV.

Plantar fasciitis: A randomized comparative study of platelet rich plasma and low dose radiation in sportspersons.

BACKGROUND: Plantar Fasciitis makes up about 15% of patients requiring professional care due to foot symptoms. The treatment methods are numerous with none proving to be clearly superior to others. We aimed to compare two common treatment methods in search of the best treatment. METHOD: All consecutive sportspersons presenting to our OPD with clinical diagnosis of plantar fasciitis underwent treatment consisting of stretching exercises, activity modification, and NSAID's for 6 months. First 40 patients who did not respond to the treatment were divided randomly into two groups of 20 patients each, Group A (Platelet rich plasma - PRP) and Group B (low dose radiation - LDR). At the time of final follow-up (6 months) the mean improvement in the pain score (Visual-Analogue-Scale), American Orthopaedic Foot and Ankle Score (AOFAS) and Plantar fascia thickness on ultrasound were compared. RESULT: Significant improvement in all 3 parameters was noted at the time of final follow up within both groups. When compared to each other, the difference in outcome of both these Groups on the given 3 parameters came out to be insignificant (p>0.05). CONCLUSION: PRP is as good as LDR in patients with chronic recalcitrant plantar fasciitis not responding to physical therapy.

Pre-pubescent posterior cruciate ligament (PCL) reconstruction using maternal allograft.

PURPOSE: Posterior cruciate ligament (PCL) reconstruction is a challenge in the pre-pubescent and paediatric age group. It requires great skill in tunnel and graft placement and fixation through open physes. Another major concern is the source of graft, as the thickness of harvested hamstring graft is unpredictable in children and the bone patella tendon bone graft cannot be used due to un-ossified patella and tibial tuberosity. Quadriceps being an important agonist of PCL, we decided not to use it as a graft source. METHODS: PCL reconstruction was done in three pre-pubescent children aged 3.5, 7 and 10 years using maternal allograft with follow-up of 7, 9 and 7 years (the 10-year-old boy was lost to follow-up after 2013), respectively. RESULTS: All the patients showed excellent results with the median IKDC Pedi improving to 90 (85-92) at latest follow-up as against 29.9 (25-35) pre-operatively. The median Lysholm score improved from 45 (42-47) to 100 (95-100). The posterior drawer test showed no PCL laxity during the latest follow-up. The grafts were accepted well by all three with no evidence of graft rejection or tissue reaction. CONCLUSION: Living donor allografts may be a good option for paediatric ligament reconstruction. This, however, must be supported with more evidence from a larger study group and a longer follow-up until the closure of physes. LEVEL OF EVIDENCE: IV.

Atraumatic Myositis Ossificans of Iliopsoas Excised through an ASIS Osteotomy: Case Report and Description of a Novel Technique.

With a well-established incidence of 15% to 20% following a spinal injury, the occurrence of neurogenic myositis ossificans of the hip is quite rare. The most widely accepted theory supporting its occurrence is the repeated microtrauma by forceful passive mobilization during rehabilitation. An extensive involvement around the hip is quite disabling to the patient. We present the case of a 41-year-old man with an extensive involvement of the right iliopsoas following an incident of head injury with no primary injury to the hip, with a disabling restriction of movement. Computed tomography images and its 3D reconstruction were used to define the exact extent of involvement. The mass was excised piece meal using the iliofemoral approach with an osteotomy of the anterior superior iliac spine, which allowed us to have a better visualization to the extensive mass. Postoperatively the patient regained a good range of motion. In addition to adding a rare case of atraumatic myositis ossificans of the iliopsoas to literature, this reports describes a novel approach for its excision.

Arthroscopic anatomical double bundle anterior cruciate ligament reconstruction: A prospective longitudinal study.

BACKGROUND: Single bundle anterior cruciate ligament (ACL) reconstruction has been the current standard of treatment for ACL deficiency. However, a significant subset of patients continue to report residual symptoms of instability with a poor pivot control. Cadaveric biomechanical studies have shown double bundle (DB) ACL reconstructions to restore the knee kinematics better. This study evaluates the outcome of DB ACL reconstruction. MATERIALS AND METHODS: 30 consecutive patients who underwent anatomic DB ACL reconstruction were included in this prospective longitudinal study. There were all males with a mean age of 25 ± 7.45 years. All patients were prospectively evaluated using GeNouRoB (GNRB) arthrometer, functional knee scores (International Knee Documentation Committee [IKDC] and Lysholm) and postoperative magnetic resonance imaging (MRI) for comparing the graft orientation and footprint of the reconstructed ACL with that of the normal knee. RESULTS: The average followup was 36.2 months. At the time of final followup the mean Lysholm score was 93.13 ± 3.31. As per the objective IKDC score, 26 patients (86.6%) were in Group A while 4 patients (13.3%) were in Group B. The mean differential anterior tibial translation by GNRB, arthrometer was 1.07 ± 0.8 mm (range 0.1-2.3 mm). All cases had a negative pivot shift test. MRI scans of operated and the contralateral normal knee showed the mean sagittal ACL tibial angle coronal ACL tibial angle and tibial ACL footprint to be in accordance with the values of the contralateral, normal knee. CONCLUSION: The study demonstrates that DB ACL reconstruction restores the ACL anatomically in terms of size and angle of orientation. However, long term studies are needed to further substantiate its role in decreasing the incidence of early osteoarthritic changes compared to the conventional single bundle reconstructions.

Contralateral reversed distal femoral locking plate for fixation of subtrochanteric femoral fractures.

PURPOSE: Subtrochanteric fractures of the femur are being managed successfully with various intramedullary and extramedulary implants with reasonable success. However, these implants require precise placement under image intensifier guidance, which exposes the surgeon to substantial amount of radiation. It also restricts the management of these fractures at peripheral centers where facility of image intensifiers is not available. Keeping this in mind we designed this study to identify if contralateral reversed distal femoral locking plate can be used successfully without the use of image intensifier. METHODS: Twenty-four consecutive patients (18 men and 6 women) with a mean age of 28 years (range 19-47 years) suffering subtrochanteric fractures of the femur underwent open reduction and internal fixation with reversed contralateral distal femoral locking plate. The outcome was assessed at the mean follow-up period of 3.2 years (range 2-4.6 years) using the Harris hip score. RESULTS: Twenty-one fractures united with the primary procedure, with a mean time of consolidation being 11 weeks (range, 9-16 weeks). One patient developed superficial suture line infection, which resolved with oral antibiotics. Another patient had a fall 3 weeks after surgery and broke the plate. Repeat surgery with reversed distal femoral locking compression plate was performed along with bone grafting and the fracture united. Two cases had nonunion, which went in for union after bone grafting. The mean Harris hip score at the time of final follow-up was 90.63 (range 82-97). CONCLUSION: The reversed contralateral distal femoral plate is a biomechanically sound implant, which when used for fixation of the subtrochanteric fractures with minimal soft tissue stripping shows results comparable to those achieved by using other extramedullary implants as well as intramedullary devices. The added advantage of this implant is its usability in the absence of an image intensifier.

Mini incision acromio-clavicular joint reconstruction using palmaris longus tendon graft.

INTRODUCTION: Conservatively managed acromio-clavicular dislocations leave the patients with significant disability. Various techniques have been described to manage such injuries operatively. However, all such techniques involve exposure of the coracoid and use of metallic implants. We present a series of eight patients managed with small incision and minimal soft tissue dissection using palmaris longus tendon graft. We treated eight patients (all males), with acute acromio-clavicular dislocation with a palmaris Longus tendon graft. MATERIAL AND METHOD: The mean age of the patients at the time of final follow-up was 28.5 years (range 26-29 years), and the mean follow-up was 18 months (range 14-28 months). Functional assessment was done as per the DASH scores, along with a self-evaluation of the results. The vertical acromio-clavicular distance at final follow-up was compared to that at the time of presentation. RESULTS: The mean DASH score at final follow-up was 3.01; on self-evaluation, all patients rated their result as good. The patients had no or minimal pain at final follow-up. The mean vertical acromio-clavicular distance reduced from a mean pre-operative baseline values of 10.26 ± 2-1.40 ± 0.855 mm at latest follow-up. DISCUSSION: This is a mechanically sound technique, which required a small incision and minimal soft tissue dissection. It also does not require exposure of the coracoid, thus almost ruling out chances of significant neuro-vascular injury. The patients did not require any second surgery for implant removal. However, a longer follow-up with a larger number of patients is required to evaluate its long-term results and stability of the repair. CONCLUSION: Acromio-clavicular reconstruction using the palmaris Longus tendon graft is a simple surgery worth trying by a surgeon not proficient in arthroscopic techniques.

Hypertrophic nonunion humerus mimicking an enchondroma.

Introduction. Although fractures of humeral shaft show excellent results with conservative management, nonunion does occur. Case Report. We bring forth the case of a young male with a 1.5-year-old hypertrophic nonunion of the humerus mimicking an enchondroma. The initial X-ray images of the patient appeared to be an enchondroma, which only on further evaluation and histopathological analysis was diagnosed conclusively to be a hypertrophic nonunion. Discussion. Enchondromas are often incidentally diagnosed benign tumours. It is however not common to misdiagnose a hypertrophic nonunion to be an enchondroma. We present this case to highlight the unique diagnostic dilemma the treating team had to face.

Long term results after surgical management of posterior wall acetabular fractures.

BACKGROUND: Posterior wall fractures are the most common of all acetabular fractures, and there is universal consensus that displaced fractures are best treated with anatomical reduction and stable internal fixation. Though early and mid term results for such studies are available, few shed light on long term results. This study was performed to evaluate long term functional and radiological outcomes in patients with posterior wall acetabular fractures and to determine factors that may contribute adversely to a satisfactory final outcome. MATERIALS AND METHODS: We retrospectively analysed the hospital records for patients who underwent open reduction and internal fixation (ORIF) for posterior wall acetabular fractures. Twenty-five patients (20 men, five women), including one with bilateral posterior wall fracture, with a mean age of 41.28 ± 7.16 years (range 25-60 years) and a mean follow-up of 12.92 ± 6.36 years (range 5-22 years) who met the inclusion criteria formed the study cohort. Matta's criteria were used to grade postoperative reduction and final radiological outcome. Functional outcome at final follow-up was assessed according to d'Aubigné and Postel score. RESULTS: Anatomic reduction was achieved in 22 hips, imperfect in four and poor in none. Radiological outcome at final follow-up revealed excellent results in ten hips, good in eight, fair in five and poor in three. The final d'Aubigné and Postel scores were excellent in 14 hips, good in six and fair and poor in three each. Patients with anatomical reduction had a favourable functional and radiological long term outcome. However, the presence of associated injuries in lower limbs and a body mass index (BMI) >25 adversely affected the final functional outcome. Osteonecrosis was seen in three patients, heterotopic ossification in two and Morel Lavallee lesion in one. One patient had postoperative sciatic nerve palsy, which recovered 6 weeks after surgery. CONCLUSION: Anatomic postoperative reduction leads to optimal functional and radiological outcome on long term follow-up; however, the presence of associated lower-limb injuries and BMI >25 adversely affects a satisfactory final outcome in patients with posterior wall acetabular fractures. LEVEL OF EVIDENCE: (Level 4) Retrospective case series.

Ossicle in anterior cruciate ligament: a rare occurrence.

The occurrence of an intra-articular ossicle is not rare in the knee, with reports suggesting the existence of meniscal osscile. There are also reports describing the attachment of the posterolateral bundle of the anterior cruciate ligament (ACL) to an accessory ossicle. However, despite an extensive search of the English literature we did not find much written about an intrasubstance ossicle in the ACL. We present the case of a 13-year-old male with an intrasubstance ossicle in the anteromedial bundle of the ACL of his right knee.

Osteosynthesis with long volar locking plates for metaphyseal-diaphyseal fractures of the distal radius.

OBJECTIVE: Metaphyseal-diaphyseal fractures of the distal radius are a major treatment dilemma and orthopaedic surgeons have to pay due consideration to restoration of anatomy of distal radius together with rotation of the radial shaft and maintenance of radial bow and interosseous space. We performed this study to evaluate the clinic-radiological outcome of metaphyseal-diaphyseal fractures of the distal radius treated with long volar locking plates. METHODS: This prospective study involved 27 patients (22 males and 5 females) with metaphyseal-diaphyseal fracture of the distal radius. Their mean age was (30.12+/-11.48) years (range 19-52 years) and the follow-up was 26.8 months (range 22-34 months). All patients underwent open reduction and internal fixation with a long volar locking plate. According to AO/OTA classification, there were 7 type A3, 13 type C2 and 7 type C3 fractures. Subjective assessment was done based on the disabilities of the arm, shoulder and hand (DASH) questionnaire. Functional evaluation was done by measuring grip strength and range of motion around the wrist and the radiological determinants included radial angle, radial length, volar angle and ulnar variance. The final assessment was done according to Gartland and Werley scoring system. RESULTS: Postoperative radiological parameters were well maintained throughout the trial, and there was significant improvement in the functional parameters from 6 weeks to final follow-up. The average DASH scores improved from 37.5 at 6 weeks to 4.2 at final follow-up. Final assessment using Gartland and Werley scoring system revealed 66.67% (n equal to 18) excellent and 33.33% (n equal to 9) good results. There was one case of superficial infection which responded to antibiotics and another carpel tunnel syndrome which was managed conservatively. CONCLUSION: Volar locking plate fixation for metaphyseal-diaphyseal fractures of distal radius is associated with excellent to good functional outcome, early rehabilitation and minimal complications.

Combined radial and median nerve injury in diaphyseal fracture of humerus: a case report.

Radial nerve palsy is the most common neurological involvement in humeral shaft fractures. But combined radial and median nerve injury in a closed diaphyseal fracture of the humerus is rare. Combined injury to both radial and median nerve can cause significant disability. A detailed clinical examination is therefore necessary following humeral shaft fractures. We report a patient with closed diaphyseal humeral fracture (AO 12A-2.3) together with radial and median nerve palsy, its management and review of the literature. As the patient had two nerves involved, surgical exploration was planned. Fracture was reduced and fixed with a 4.5 mm narrow dynamic compression plate. There was no external injury to both radial and median nerves on surgical exploration. Neurological recovery started at 3 weeks' follow-up. Complete recovery was seen at 12 weeks. Careful clinical examination is of the utmost importance in early diagnosis of combined nerve injuries, which allows better management and rehabilitation of the patient.

Double floating arm injury in a child: a case report and review of the literature.

The combination of ipsilateral humeral fractures at three different levels namely proximal, shaft and supracondyle has been rarely defined in the literature. We present a case report on such a complex injury in a 10-year-old child after falling down from the second floor of his house while playing. To the best of our knowledge, no such case report exists in the English literature. We define it as double floating arm injury. Firstly, shaft of humerus was open reduced and fixed with 4.5 mm narrow dynamic compression plate. Then closed reduction and pinning of the supracondylar humerus under an image intensifier was obtained. Open reduction using deltopectoral approach to the proximal humerus was done and the fracture was fixed with three K-wires. Ipsilateral multiple fractures in children often result from high energy trauma. Immediate reduction and fixation is required. Usually surgeons need to treat simple fractures firstly, which makes the subsequent treatment of complex fractures easier.