No Clear Difference in Clinical Outcomes Between Knotted and Knotless Arthroscopic Bankart Repair: A Systematic Review.

PURPOSE: The objective of the current study was to analyze if the arthroscopic Bankart repair using a knotless suture anchor has a better functional outcome than the conventional knot-tying Bankart repair. METHODS: Comprehensive literature search was done in Pubmed, Scopus, Embase, and Cochrane databases in May 2023. Studies comparing the clinical outcome of Bankart repair using knotless and knot-tying techniques were included in the study. In vitro, animal, and level 4 and 5 studies were excluded. The risk of bias of randomized controlled trials (RCT) was calculated according to the RoB 2 tool, and for non-randomized studies, MINORS criteria were used. Statistical analysis was done using RevMan software. RESULTS: A total of nine studies, including two RCT and seven non-randomized comparative studies involving 720 patients, were included in the systematic review. The ROWE score ranged 81.7 to 94.3 in the knot-tying and 86 to 96.3 in the knotless group. VAS scores at final follow-up ranged between 0.1 to 1.7 in the knot-tying and 0.7 to 2.5 in the knotless group. The rate of redislocation, subluxation, and revision surgery in the knot-tying group ranged from 0 to 14.7%, 16.7 to 29.7%, and 1.6 to 17.6%, respectively, while that in the knotless group ranged from 2.4 to 23.8%, 7.4 to 22.2%, and 2.4 to 19%, respectively. The mean external rotation was 54 to 65 degrees in the knot-tying and 61 to 99 in the knotless group. The mean forward-flexion was 164 to 172 in the knot-tying and 165 to 174 in the knotless group. Our subjective synthesis doesn't reveal any difference in the outcome between the two groups. CONCLUSION: The available literature does not demonstrate a clear difference in functional outcomes, residual pain, and rate of complications like redislocation, subluxation and revision surgery between Bankart repair performed with knotted and knotless anchors.

Is mandible derived mesenchymal stromal cells superior in proliferation and regeneration to long bone-derived mesenchymal stromal cells?

Mesenchymal stromal cells (MSCs) are cells with the characteristic ability of self-renewal along with the ability to exhibit multilineage differentiation. Bone marrow (BM) is the first tissue in which MSCs were identified and BM-MSCs are most commonly used among various MSCs in clinical settings. MSCs can stimulate and promote osseous regeneration. Due to the difference in the development of long bones and craniofacial bones, the mandibular-derived MSCs (M-MSCs) have distinct differentiation characteristics as compared to that of long bones. Both mandibular and long bone-derived MSCs are positive for MSC-associated markers such as CD-73, -105, and -106, stage-specific embryonic antigen 4 and Octamer-4, and negative for hematopoietic markers such as CD-14, -34, and -45. As the M-MSCs are derived from neural crest cells, they have embryogenic cells which promote bone repair and high osteogenic potential. In vitro and in vivo animal-based studies demonstrate a higher rate of proliferation and high osteogenic potential for M-MSCs as compared to long-bones MSCs, but in vivo studies in human subjects are lacking. The BM-MSCs have their advantages and limitations. M-MSCs may be utilized as an alternative source of MSCs which can be utilized for tissue engineering and promoting the regeneration of bone. M-MSCs may have potential advantages in the repair of craniofacial or orofacial defects. Considering the utility of M-MSCs in the field of orthopaedics, we have discussed various unresolved questions, which need to be explored for their better utility in clinical practice.

Legally Sound, Evidence-Based Informed Consent Form for Total Hip Arthroplasty.

Introduction: Informed consent documentation is often the first area of interest for lawyers and insurers when a medico-legal malpractice suit is concerned. However, there is a lack of uniformity and standard procedure for obtaining informed consent for total hip arthroplasty (THA). We aimed to develop a solution for this need for a pre-designed, evidence-based informed consent form for THA cases. Materials and Methods: We extensively reviewed the literature on the medico-legal aspects of THA, medico-legal aspects of informed consent, and medico-legal aspects of informed consent in THA. We then conducted semi-structured interviews with orthopaedic surgeons and patients who had previously undergone THA in the previous year. Based on all of the above, we developed an informed consent form that was evidence-based. We then had the form reviewed by a legal expert. The final form was utilised for THA cases at our institution for 1 year. Results: Legally sound, evidence-based Informed Consent Form for Total Hip Arthroplasty is given in Form A. Conclusion: The use of legally sound, evidence-based informed consent for total hip arthroplasty cases would be beneficial to orthopaedic surgeons and patients alike. It would uphold the rights of the patient, and promote open discussion and transparency. In the event of a lawsuit, it would be a vital document in the defence of the surgeon and withstand the scrutiny of lawyers and the judiciary.

Evolution and Clinical Advances of Platelet-Rich Fibrin in Musculoskeletal Regeneration.

Over the past few decades, various forms of platelet concentrates have evolved with significant clinical utility. The newer generation products, including leukocyte-platelet-rich fibrin (L-PRF) and advanced platelet-rich fibrin (A-PRF), have shown superior biological properties in musculoskeletal regeneration than the first-generation concentrates, such as platelet-rich plasma (PRP) and plasma rich in growth factors. These newer platelet concentrates have a complete matrix of physiological fibrin that acts as a scaffold with a three-dimensional (3D) architecture. Further, it facilitates intercellular signaling and migration, thereby promoting angiogenic, chondrogenic, and osteogenic activities. A-PRF with higher leukocyte inclusion possesses antimicrobial activity than the first generations. Due to the presence of enormous amounts of growth factors and anti-inflammatory cytokines that are released, A-PRF has the potential to replicate the various physiological and immunological factors of wound healing. In addition, there are more neutrophils, monocytes, and macrophages, all of which secrete essential chemotactic molecules. As a result, both L-PRF and A-PRF are used in the management of musculoskeletal conditions, such as chondral injuries, tendinopathies, tissue regeneration, and other sports-related injuries. In addition to this, its applications have been expanded to include the fields of reconstructive cosmetic surgery, wound healing in diabetic patients, and maxillofacial surgeries.

Management of Thrombosis of the External Iliac Artery during Total Hip Arthroplasty - A Case Report.

Introduction: Vascular injury following total hip arthroplasty (THA) is uncommon but can lead to loss of life or limb. External iliac and common femoral arteries are commonly injured during THA. Case Report: We report a case of thrombosis of the external iliac and femoral artery during THA in a mid-60-year female patient with 15-year-old neglected fracture neck of the femur. Six hours following THA through Harding's approach, a feeble pulse was palpated in the operated limb. Ischemia of the limb led to sciatic nerve palsy and foot drop in the operated limb, which was intact following surgery. Computed tomography angiography confirmed thrombosis of the external iliac and femoral artery. Removal of thrombosis with the use of a Fogarty catheter could save the limb and lead to recovery of foot drop. Early detection of pulselessness and timely intervention in the post-operative period was the cornerstone of this case report. Conclusion: Vascular injury during THA though rare but cannot be ruled out completely. Early diagnosis with a stringent post-operative protocol and timely intervention would be the cornerstone of the management of any vascular injury following THA.

Complications and Difficulties Encountered in the Management of a Neglected Osteoporotic Proximal Humerus Fracture.

Introduction: Osteoporosis is a known complication of prolonged steroid therapy. Osteoporotic fracture is common in such a scenario and poses several challenges in its management. We present a case of neglected proximal humerus fracture in a 57-year-old osteoporotic female and the difficulties encountered in its management. Case Report: A 57- year-old female, rheumatoid arthritis patient, is on steroids for the past ten years. Four years back, she sustained a fracture of the left humerus neck following a trivial trauma. The fracture was not managed by an orthopaedician and was treated by a general practitioner. She presented to us in a state of painless displaced non-union of fragments with severe osteoporosis. DEXA scan revealed severe osteoporosis. She was started on oral calcium, magnesium, and vitamin D supplementation. Along with oral supplementation, the patient was advised 20 mcg of Teriparatide subcutaneously once daily and single dose of Denosumab 60 mg subcutaneously. Non -vascularized free fibular graft was harvested from the ipsilateral lower limb. A five-hole PHILOS plate was used to fix the fracture. Intra-operatively, the humeral head appeared too indistinct under fluoroscopy leading to difficulty in estimating screw length. An indirect method was used to assess the screw length. The post-operative radiograph was satisfactory but radiograph after two weeks showed an un-displaced fracture adjacent to the distal end of the plate. It was decided to continue with conservative management by a "'U"' cast. A follow- up radiograph at three months showed complete union of the stress fracture at the distal end of the plate end and progressive union of the fracture at the primary site. But En- block pull-out of the locking plate was noticed in the distal fragment of the fracture in the follow-up radiograph at 9 months from surgery. The limb was further immobilized in an arm sling for more four weeks. At one year from operation, there was good union of fracture with acceptable shoulder movement. Conclusion: Osteoporotic fractures are often difficult to treat. Careful pre-operative planning, active osteoporosis management, good implant selection, careful bone handling, and judicious rehabilitation are key to avoid complications and achieve good functional outcome.

Early Accelerated versus Delayed Conservative Rehabilitation Protocol after Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial.

Objective To compare the effectiveness of the early accelerated rehabilitation and delayed conservative rehabilitation protocols after arthroscopic anterior cruciate ligament reconstruction, in terms of the International Knee Documentation Committee (IKDC) score, pain (according to the Visual Analog Scale), laxity, and stiffness one year postoperatively to determine the best outcome. Materials and Methods A total of 80 subjects were divided into 2e groups (early accelerated group and delayed conservative group), which were analyzed by the Pearson Chi-squared and Wilcoxon rank-sum tests. Results One year postoperatively, knee laxity was significantly higher ( p = 0.039) in the early accelerated group compared with the delayed conservative group. Regarding postoperative pain (according to the Visual Analogue Scale) and IKDC scores, both groups presented similar results. The postoperative range of motion was better in the early accelerated group, but this was not statistically significant ( p = 0.36). Conclusion One year postoperatively, the early accelerated rehabilitation protocol was associated with significant knee laxity compared to the delayed conservative rehabilitation protocol.

Early Accelerated versus Delayed Conservative Rehabilitation Protocol after Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial / Protocolo de reabilitação acelerada precoce versus conservadora retardada após reconstrução do ligamento cruzado anterior: Um ensaio prospectivo randomizado

Abstract Objective To compare the effectiveness of the early accelerated rehabilitation and delayed conservative rehabilitation protocols after arthroscopic anterior cruciate ligament reconstruction, in terms of the International Knee Documentation Committee (IKDC) score, pain (according to the Visual Analog Scale), laxity, and stiffness one year postoperatively to determine the best outcome. Materials and Methods A total of 80 subjects were divided into 2e groups (early accelerated group and delayed conservative group), which were analyzed by the Pearson Chi-squared and Wilcoxon rank-sum tests. Results One year postoperatively, knee laxity was significantly higher (p = 0.039) in the early accelerated group compared with the delayed conservative group. Regarding postoperative pain (according to the Visual Analogue Scale) and IKDC scores, both groups presented similar results. The postoperative range of motion was better in the early accelerated group, but this was not statistically significant (p = 0.36). Conclusion One year postoperatively, the early accelerated rehabilitation protocol was associated with significant knee laxity compared to the delayed conservative rehabilitation protocol.

Resumo Objetivo Comparar a eficácia dos protocolos de reabilitação acelerada precoce e de reabilitação conservadora retardada após reconstrução artroscópica do ligamento cruzado anterior, em termos da escala do International Knee Documentation Committee (IKDC), da dor (segundo a Escala Visual Analógica), da frouxidão e da rigidez no pós-operatório de um ano para determinar o melhor desfecho. Materiais e Métodos Um total de 80 participantes foram divididos em dois grupos (grupo da acelerada precoce e grupo da conservadora retardada), que foram analisados pelos testes do Qui-quadrado de Pearson e da soma dos postos de Wilcoxon. Resultados A frouxidão do joelho no pós-operatório de 1 ano foi significativamente mais alta (p = 0,039) no grupo da acelerada precoce do que no grupo da conservadora retardada. Em termos de dor pós-operatória (pela Escala Visual Analógica) e pontuações no IKDC, ambos os grupos apresentaram resultados similares. A amplitude de movimento pós-operatória foi melhor no grupo da acelerada precoce, mas isso não foi estatisticamente significativo (p = 0,36). Conclusão O protocolo de reabilitação acelerada precoce foi associado com uma frouxidão significativa do joelho em um ano de pós-operatório em comparação com o protocolo de reabilitação conservadora retardada.

Traumatized periosteum: Its histology, viability, and clinical significance.

The periosteum covers the surface of long bone except at the joints. During fracture fixation, we found the periosteum is ragged and damaged. Our objective is to determine the microscopic picture of traumatized periosteum in terms of the degree of damage, cell type, stromal tissue, and vascularity. Periosteum of 1cm*1cm is harvested at 1cm, 3cm, and 5cm proximal and distal to fracture site following fracture of a long bone in 20 humans. Ragged and damaged periosteum mainly consists of an outer fibrous layer with many hemorrhagic tissue and neovascularization. Osteoprogenitor cells were seen only in 12 out of 97 samples, mostly harvested 5 cm from the fracture site. The innermost layer of the periosteum remains attached to the bone surface after separating the fibrous layer following a fracture. The use of a periosteal elevator on the bone surface further damages the inner layer of the periosteum. Using a scalpel to separate the periosteum or merely pulling it away from the bone surface will decrease damage to the inner cambium layer. Fracture reduction can be achieved by indirect means at least 5 cm away from the fracture site.

Management of Neglected Patellar Tendon Rupture by Peroneus Longus Autograft and Suture Anchor: A Case Report.

Introduction: Patellar tendon rupture is a rare injury and is often missed in primary and secondary care centers because of non-visibility in X-rays. Neglected rupture is even rarer and gives rise to significant disability. These injuries are technically difficult to repair with invariably poor functional outcomes. This needs reconstruction with allograft or autograft with or without augmentation. We report such a case of neglected patellar tendon injury treated with peroneus longus autograft. Case Report: A 37-year-old male patient presented with limping and inability to do a full extension of the knee. There is a history of a lacerated wound over the knee following a bike accident. Reconstruction was done with peroneus longus auto graft by making a trans-osseous tunnel through the patella and tibial tuberosity in the Figure eight 8 manner and fixed by a suture anchor. Postoperatively, the patient was doing well at a 1-year follow-up. Conclusion: Good clinical outcomes can be achieved in neglected patellar tendon rupture by auto graft without augmentation.

Non-suppurative Tissue Reaction to Polyether Ether Ketone Anchor in Rotator Cuff Repair.

Introduction: Interferential screws and anchors have played a major role in fixation of soft tissue to bony tunnel. With advent of time, there developed metal anchors, biodegradable anchors, bioinert anchors, etc. Biodegradable anchors had complications such as reactive synovitis, cyst formation, soft-tissue inflammation, and local osteolysis. Polyether ether ketone (PEEK) which was biologically inert and radiolucent was introduced to overcome the disadvantages of anchors. We present a case of non-suppurative tissue reaction to PEEK anchor following rotator cuff repair. Case Report: A 58-year-old male patient presented to us with signs of rotator cuff tear following injury to his shoulder. Magnetic resonance imaging depicted a massive cuff tear with retraction of cuff. Considering the degree of cuff tear, cuff was repaired with mini open method using two metallic suture anchor and two PEEK knotless bioraptor foot print suture anchor. Surgical wound healing was uneventful and suture was removed on 14th day following surgery. Three weeks following surgery, the patient had pain and rise in temperature over shoulder with raised erythrocyte sedimentation rate and C-reactive protein which subsided in 7 days with empirical antibiotics. Later, at 3 months, the patient had serous discharge from surgical site, on which exploration revealed pale yellow material vicinity to PEEK anchor. Other than pus cells in smear, discharge was negative to routine culture, grams stain, and cartridge-based nucleic acid amplification test for tuberculosis. Surprisingly, surrounding muscles were healthy, red in color, and contracting to stimulation. Following removal of both the PEEK anchors, local symptoms subsided with improvement in patients shoulder function. Conclusion: There were cases of tissue reaction to PEEK material in the literature such as osteolysis and cyst formation. In addition, non-suppurative inflammation can occur in response to PEEK material. Awareness about the non-suppurative inflammation property of PEEK material may help future surgeons to manage the condition better than us.

Pattern of injuries due to wild animal attack among patients presenting to the emergency department: A retrospective observational study.

PURPOSE: The human-wildlife conflicts (HWCs) causing nuisances and injuries are becoming a growing public health concern over recent years worldwide. We aimed to study the demographic profile, mode of injury, pattern of injury, and outcome of wild animal attack victims presented to the emergency department. METHODS: This retrospective cross-sectional study was conducted in the emergency department of a tertiary-care hospital in Eastern India. Data were retrieved from the medical records from May 2017 to May 2021. Patients of all ages and genders attacked by wild animals and secondary injuries were included in this study. Patients with incomplete data, injuries due to the attack of stray and domestic animals and trauma due to other causes were excluded. Demographic profile, mode of injury, the pattern of injury, injury severity score (ISS), radiological pattern, and outcome were recorded. Statistical analysis with R (version 3.6.1.) was conducted. RESULTS: A total of 411 wild animal attack victims were studied, of which 374 (90.9%) were snakebite injuries and 37 (9.1%) were wild mammalian (WM) attack injuries. The mean age of WM attack victims was 46 years, and the male-to-female ratio was 4:1. Elephant attack injury (40.5%) was the most common WM attack injury reported. Most WM attacks (43.2%) occurred between 4:00 a.m. to 8:00 a.m. The median ISS was 18.5 (13-28), where 54.2% of patients had polytrauma (ISS>15). Elephant attack was associated with a higher ISS, but the difference was not significant compared to other animal types (p = 0.2). Blunt trauma was common pattern of injury in the elephant attack injury cases. Lacerations and soft tissue injuries were common patterns in other animal attacks. Among snakebites, neurotoxic was the most common type (55.4%), and lower extremity was the most common site involved. CONCLUSION: The young male population is the major victim of HWCs; and elephant is the most common animal involved. There is a need to design scientifically sound preventive strategies for HWCs and to strengthen the preparedness in health establishments to manage victims effectively.

Ribbing disease of tibia: a rare entity.

Establishing the cause of unilateral leg pain is difficult in the settings of tibial diaphyseal sclerosis. This patient, a 36-year-old woman presented with unilateral pretibial leg pain for past 7 months without history of trauma, infections, systemic or metabolic disease. Besides local deep tenderness, other clinical findings and blood investigations were normal. Radiograph and CT scan showed both periosteal and endosteal cortical thickening with obliteration of medulla of the tibial midshaft. MRI scan detected marrow oedema and bone scan revealed increased tracer uptake at the affected site of tibia. She was treated by saucerisation and re-establishment of the medullary canal. Biopsy of the harvested tissue had trabecular bone without any sign of inflammation. Patient was pain free after 3 months of operation and was able to perform her activity of daily living without any difficulties. Ribbing disease is a disease of exclusion and need high degree of suspicion for its diagnosis.

Hydatid Cyst of Dorsal Spine Masquerading as Tubercular Infection: A Case Report and Review of Literature.

Hydatid cyst disease of the spine is rare, and only a few are reported in the scientific literature. This infection is caused by the larvae of Echinococcus granulosus cestode. The presentation is usually late because the patient remains asymptomatic for a longer duration after the infection. The initial form of treatment is always surgical in a symptomatic patient for excision of the diseased tissue. A 35-year-old male presented in the outpatient department with a chief complaint of mid-back pain and intermittent history of fever following his back surgery for 4 years. The patient has taken presumptive treatment for tuberculosis before presenting it to us. Radiological investigations dictate the presence of hydatid cyst in the D4 vertebra. Intact cysts were excised with perioperative albendazole coverage. The patient was mobilized on postoperative day-1 with Taylor's brace, and the brace was continued for 6 weeks. The patient was followed up at regular intervals for 1 year, and no recurrence was found. Hydatid cyst disease in the spine is a rare disease but associated with high morbidity despite significant advances in diagnostic imaging techniques and surgical treatment. For a provisional diagnosis, magnetic resonance imaging is the investigation of choice. Surgical decompression is the main stray of treatment along with antihelminthic therapy. A close follow-up is required after the initial treatment to find the recurrence at the earliest.

Compartment syndrome as a late presentation of brachial artery pseudoaneurysm following shaft of humerus fracture.

Peripheral artery pseudoaneurysm is rare in upper extremities compared with lower extremities. Early diagnosis and prompt management are two cornerstones of successful outcomes in these cases. Delay can lead to limb and life-threatening complications. We present a case of compartment syndrome of upper limb as a sequel to pseudoaneurysm of brachial artery for which we had to do shoulder disarticulation. The patient recovered uneventfully.