The Outcome of Arthroscopic Anterior Cruciate Ligament Reconstruction in Low-Demand, Non-athletic Patients Following a Home-Based Rehabilitation Protocol.

BACKGROUND: Arthroscopic anterior cruciate ligament (ACL) reconstruction is a common orthopedic procedure. Most of the literature is on high-demand athletic patients, with little information about the outcomes of low-demand patients. Therefore, we aim to assess the outcomes of non-athletic patients following home-based rehabilitation. METHODS: An observational cross-sectional comparative study was conducted with 30 non-athletic adults with ACL injuries whose pre-injury Tegner activity level was four or less. After six months of reconstruction, patients were assessed for functional outcomes using the Tegner activity level, Lysholm score, International Knee Documentation Committee (IKDC) score, and ACL quality of life (QOL) score. Functional performance was assessed by the carioca test, one-leg hop test, and shuttle test. Functional outcome and performance were compared with an age, sex, and activity level-matched group. Knee stability was assessed by Lachman, anterior drawer, and pivot shift. RESULTS: All patients returned to their pre-injury Tegner activity level. A statistically significant difference was seen in the Lysholm score, IKDC score, ACL QOL score, carioca test, shuttle test, and one leg hop test (p= <0.001 in each); >5mm of translation of the tibia in the Lachman test was seen in three patients, whereas one patient had >5 mm of translation in the anterior drawer test but pivot shift was absent in all. CONCLUSION: We found that all patients returned to their pre-injury Tegner activity level. Most patients had improved knee stability; however, functional outcomes and performance were lower compared to the control group. Therefore, arthroscopic ACL reconstruction is a reasonable treatment option for non-athletic, low-demand patients to get back to their pre-injury functional activity level.

Comparison between reliability of Schatzker's classification and CT based four quadrant classification for tibial plateau fractures.

Introduction: Conventionally used Schatzker and AO/OTA classification, do not identify posterior column injuries in tibial plateau fractures. CT based Four quadrant classification, has been proposed to identify fractures of tibial plateau and help in surgical planning of treatment. However, to assess its validity, there is scanty literature about its reliability (inter and intra-observer variation) and comparison of its reliability with that of the more popular Schatzker classification in classifying tibial plateau fracture. Material and methods: X-rays and CT scans of 35 patients (18-65 years) of closed tibial plateau fractures were assessed by 5 Orthopaedic surgeons and classified by both Schatzker's and Four Quadrant Classification. A similar observation was recorded after 2 months. All observers were blinded for the demographic and clinical details of the patients. Their responses were noted and interobserver and Intraobserver variation was calculated. Kappa Test of Cohen was used to determine the level of agreement, as per Landis and Koch's criteria. The reliability of four quadrant classification was also compared with that of Schatzker's classification. Results: There was a moderate agreement in interobserver variation in observations for Schatzker's classification (on X-rays) which improved to substantial agreement when the observations were recorded after showing both CT and X-rays. The intraobserver variation had substantial agreement. On the other hand, there was a perfect agreement in both intra- and interobserver variation for Four Quadrant Classification. This difference between the reliability of both classifications was statistically significant (p < 0.001). Conclusions: Four Quadrant classification is a more reliable classification having a better agreement on interobserver and intraobserver variation.

Outcomes of Displaced, Comminuted, Intracapsular Neck Femur Fracture in Young Adults Managed with Three Screw Inverted Triangle Versus Four Screw Diamond Configuration: A Comparative Pilot Study.

Background: Three cannulated cancellous screws (CCS) inverted triangle configuration is considered to be the gold standard for management of displaced intracapsular neck femur (ICNF) fractures in young adults. However, some authors have recommended four CCS in diamond configuration in the presence of comminution. However, there are no comparative studies to assess the superiority of one over the other. Therefore, the aim of the present study was to compare the radiological and functional outcomes of displaced, comminuted, ICNF fracture in young adults managed with three screw inverted triangle versus four screw diamond configuration CCS fixation. Material and Methods: Twenty-three patients (group I) with displaced comminuted ICNF fractures were managed with three CCS fixation in inverted triangle fashion between October 2014 and October 2015 and were followed up for a mean duration of 33.5 months (range 25-38 months). Twenty-five patients (group II) with the same inclusion and exclusion criteria were managed with four CCS in diamond configuration between October 2013 and October 2014 and followed up for a mean duration of 33.3 months (range 25-38 months). Radiological outcomes of these patients were compared in terms of union rates and avascular necrosis, while functional outcome was measured by Harris Hip Score (HHS) at a minimum of 24 months. Results: Nineteen patients of group I and 20 patients of group II were available for final follow-up. Mean union time in group I was 15 weeks (12-24 weeks), while in group II, it was 14 weeks (12-24 weeks). There was total of four (4/19) cases of non-union in group I, while it was two (2/20) cases in group II. One patient (1/19) developed avascular necrosis in group I, while two (2/20) developed the same in group II. In group I, the mean HHS was 87.3 (range 84-94) points, while in group II, mean HHS was 93.5 (range 78-96) points. Conclusion: There is no difference in the clinical and radiological outcomes following three screw inverted triangle or four screw diamond configuration CCS fixation of displaced comminuted ICNF fracture in young adults. Thus, we conclude that both three screw inverted triangle or four screw diamond configuration CCS fixation are effective treatment modalities for fracture neck femur with comminution and in the absence of larger studies and long-term follow-up the superiority of one over the other cannot be recommended.

Langerhans cell histiocytosis of the scapula - diagnosis & treatment options / Histiocitose de células de langerhans da escápula - diagnóstico e opções de tratamento / Histiocitosis de células de langerhans de la escápula - diagnóstico y opciones de tratamiento

ABSTRACT Langerhans cell histiocytosis (LCH) is characterised by an abnormal histiocytic accumulation in tissues such as the lung, spleen, bone marrow, skin, central nervous system, liver and lymph nodes, causing focal or systemic effects. No specific clinical & radiographic presentation of LCH is described in literature. This poses a diagnostic dilemma for surgeons. The scapula is the site of 3% of bone tumours, while for LCH it is the least common site. In a 10-year-old boy with isolated lesion of the scapula with no other systemic involvement, and no specific finding in MRI or CT scan of scapula, diagnosis was confirmed on biopsy. Division into single and multi-system disease is paramount in treatment, given that it is a single system disease. The patient improved clinically on follow-up of 2 years. The scapula is one of the rarest site of LCH, and because various lesions mimic each other, a biopsy is always required, with immunohistochemistry for CD68 & S-100. This was only a single system disease, so conservative management was performed, and the patent improved clinically.

RESUMO A histiocitose de células de Langerhans (HCL) caracteriza-se por acúmulo anormal de histiócitos em tecidos como pulmão, baço, medula óssea, pele, sistema nervoso central, fígado e linfonodos, causando efeitos focais ou sistêmicos. Nenhuma apresentação clínica e radiográfica específica da HCL está descrita na literatura. Isso impõe um dilema diagnóstico para os cirurgiões. A escápula é o local de 3% dos tumores ósseos, ao passo que é o lugar menos comum para a HCL. Em um menino de 10 anos de idade, com lesão isolada na escápula e sem outro envolvimento sistêmico, sem achados específicos na RM ou na TC da escápula, o diagnóstico foi confirmado pela biópsia. A divisão entre doença isolada e de múltiplos sistemas é fundamental para o tratamento, considerando-se que este caso é uma doença de um só sistema. O paciente teve melhora clínica no acompanhamento de dois anos. A escápula é um dos locais mais raros de ocorrência da HCL, e como as lesões mimetizam umas às outras, sempre é preciso realizar biópsia por imuno-histoquímica para CD68 e S-100. Esta doença atingiu apenas um sistema, levando ao tratamento conservador e o paciente apresentou melhora clínica.

RESUMEN La histiocitosis de células de Langerhans (HCL) se caracteriza por la acumulación anormal de histiocitos en tejidos como pulmón, bazo, médula ósea, piel, sistema nervioso central, hígado y linfonodos, causando efectos focales o sistémicos. Ninguna presentación clínica y radiográfica específica de la HCL está descrita en la literatura. Eso impone un dilema diagnóstico para los cirujanos. La escápula es el local de 3% de los tumores óseos, al paso que es el lugar menos común para la HCL. En un niño de 10 años de edad, con lesión aislada en la escápula y sin otro compromiso sistémico, sin hallazgos específicos en la RM o en la TC de la escápula, el diagnóstico fue confirmado por la biopsia. La división entre enfermedad aislada y de múltiples sistemas es fundamental para el tratamiento, considerándose que este caso es una enfermedad de un único sistema. El paciente tuvo mejora clínica en el acompañamiento de dos años. La escápula es uno de los locales más raros de ocurrencia de la HCL, y como las lesiones mimetizan unas a otras, siempre es preciso realizar biopsia por inmunohistoquímica para CD68 y S-100. Esta enfermedad alcanzó a sólo un sistema, llevando al tratamiento conservador y el paciente presentó mejora clínica.

Outcome of bone marrow instillation at fracture site in intracapsular fracture of femoral neck treated by head preserving surgery.

PURPOSE: The aim of present study is to evaluate the outcome of bone marrow instillation at the fracture site in fracture of intracapsular neck femur treated by head preserving surgery. METHODS: This study included 32 patients of age group 18-50 years with closed fracture of intracapsular neck femur. Patients were randomized into two groups as per the plan generated via www.randomization.com. The two groups were Group A (control), in which the fracture of intracapsular neck femur was treated by closed reduction and cannulated cancellous screw fixation, and Group B (intervention), in which additional percutaneous autologous bone marrow aspirate instillation at fracture site was done along with cannulated cancellous screw fixation. Postoperatively the union at fracture site and avascular necrosis of the femoral head were assessed on serial plain radiographs at final follow-up. Functional outcome was evaluated by Harris hip score. RESULTS: The average follow-up was 19.6 months. Twelve patients in each group had union and 4 patients had signs of nonunion. One patient from each group had avascular necrosis of the femoral head. The average Harris hip score at final follow-up in Group A was 80.50 and in Group B was 75.73, which was found to be not significant. CONCLUSION: There is no significant role of adding on bone marrow aspirate instillation at the fracture site in cases of fresh fracture of intracapsular neck femur treated by head preserving surgery in terms of accelerating the bone healing and reducing the incidence of femoral head necrosis.

Posterior dislocation of hip with ipsilateral intertrochanteric fracture: A report of two cases.

Posterior dislocations of the hip are known to be associated with fractures of the femoral head, neck, shaft, or posterior acetabular wall. However, its association with ipsilateral intertrochanteric fracture has only been anecdotally described in the English literature. We report two such cases managed by open reduction (OR) of the hip and internal fixation (IF) of the intertrochanteric fracture. The first case was a 26-year-old male who was managed by OR of the hip with IF of the intertrochanteric fracture with a dynamic hip screw and had a good functional result at 1-year followup. The second case was a 36-year-old female who was also managed by OR of the hip with IF of the head fragments with Herbert screw and IF of the intertrochanteric fracture with a dynamic condylar screw. The patient had a fair, functional result at 1-year followup. With the increase in high energy trauma, these fracture patterns have become more common, and there is an urgent need to review the existing classifications so that these fractures are better categorized, and treatment guidelines defined.

Assessment of the geometry of proximal femur for short cephalomedullary nail placement: An observational study in dry femora and living subjects.

BACKGROUND: Intramedullary devices have increasingly become popular and are widely used for fixation of unstable intertrochanteric and subtrochanteric fractures. These implants have been designed taking into consideration of the anthropometry of the western population which varies from those of other ethnic groups. This study was carried out to assess the geometry of proximal femur for the placement of short cephalomedullary nails in our subset of patients and suggest suitable design modifications based on these parameters. MATERIALS AND METHODS: The study was conducted in the following three groups: (1) Anthropometric study of 101 adult human dry femora, (2) radiographs of the same femora, and (3) radiographs of the contralateral uninjured limb of 102 patients with intertrochanteric or subtrochanteric fractures. In Group 1, standard anthropometric techniques were used to measure neck shaft angle (NSA), minimal neck width (NW), trochanteric offset, and distance from the tip of greater trochanter (GT) to the lower border of lesser trochanter on the femoral shaft axis (distance X). In Group 2 and 3, the NSA, minimal NW, NW at 130° and 135°, trochanteric shaft angle (TSA), trochanteric offset, distance X, distance between the tip of GT and the point where the neck axis crosses the line joining the tip of the GT to the lower border of the lesser trochanter on the femoral shaft axis (distance Y), and canal width at 10, 15, and 20 cm from tip of GT were measured on standard radiographs. The values obtained in these three groups were pooled to obtain mean values. Various parameters of commonly used short cephalomedullary nails available for fixation of pertrochanteric fractures were obtained. These were compared to the results obtained to suggest suitable modifications in the nail designs for our subset of patients. RESULTS: The mean parameters observed were as follows: NSA 128.07° ± 4.97 (range 107°-141°), minimum NW 29.0 ± 2.8 mm (range 22-42 mm), NW at 130° 30.12 ± 2.86 mm (range 22.2-42.5 mm), NW at 135° 30.66 ± 3.02 mm (range 22.8-40.3 mm), TSA 10.45° ± 2.34° (range 3°-15.5°), distance X 65.73 ± 6.45 mm (range 28.6-88.4 mm), distance Y 38 ± 4.91 mm (range 16.6-55.3 mm), and canal width at 10, 15, and 20 cm from the tip of GT 13.46 ± 2.34 mm, 11.40 ± 2.27 mm, and 11.64 ± 2.04 mm, respectively. CONCLUSION: The measurements of the proximal femur are not significantly different from other ethnic groups and are adequate to accept the current commonly available short cephalomedullary nails. However, certain modifications in the presently available short cephalomedullary nail designs are recommended for them to better fit the anatomy of our subset of population (a) two nails of 125° and 135°, (b) the medio-lateral angle at the level of 65 mm from the tip of the nail, (c) two femoral neck screw placements (35 and 45 mm from the tip of the nail), and (d) five different sizes of distal width for better fit in canal (9-13 mm).

Malunion in displaced intracapsular fracture of femoral neck: A rare case.

Intracapsular fracture of femoral neck is treated by anatomical reduction (preferably closed) and cannulated cancellous lag screw fixation. Malunion of these fractures have been described in the coronal plane (coxa valga or coxa vara). We reported a case of young adult patient with displaced intracapsular fracture of femoral neck that had malunited in sagittal plane with callus formation with excellent functional outcome. The radiographs revealed intracapsular fracture of femoral neck right side (Garden type 4 and Pauwel type 3). The patient was operated and closed reduction and internal fixation with three cannulated cancellous screws was performed. The postoperative radiograph revealed a loss of reduction in the lateral view. Due to this technical error, the patient was counselled for revision fixation for which he refused. At 9 months we observed union of the fracture in the displaced position by callus formation. Harris hip score at 2 years was 96 that indicate excellent functional outcome and the radiographs did not reveal any evidence of avascular necrosis of femoral head. We advised revision surgery to our patient as he had increased chances of implant failure and nonunion. However he refused the revision surgery and was continued with the suboptimal reduction. However, the fracture united and that too with callus formation, which is not a described phenomenon in neck of femur fracture.

Conjoint bicondylar Hoffa fracture in an adult.

Conjoint bicondylar Hoffa fracture is an extremely rare injury. Only one case has been reported previously in the pediatric age group. We describe this injury in a 17-year-old male who presented following a fall with direct impact on his semiflexed right knee. Plain radiographs were inadequate to define the exact pattern of injury. Computed tomographic (CT) scans demonstrated the coronal fracture involving both the femoral condyles which were joined by a bridge of intact bone. The patient was treated with open reduction and internal fixation using swashbuckler (modified anterior) approach. Union occurred within 3 months and at final followup (at 18 months) the patient had a good clinical outcome. The possible mechanism of injury is discussed.

Dome osteotomy of the pelvis using a modified trochanteric osteotomy for acetabular dysplasia.

PURPOSE: Kawamura described his dome osteotomy of the pelvis using a standard trochanteric osteotomy. Here we present results of our modification of Kawamura's dome osteotomy using a modified trochanteric osteotomy. METHODS: We retrospectively analysed 34 out of 36 patients operated upon between 1993 and 2008. We reviewed the mid-term functional and radiological results with a mean follow-up of 67 months. There were 23 females and 11 males with a mean age of 30 years. RESULTS: The mean Harris hip score improved from 60 to 85 (p < 0.05) at the final follow-up. The functional results were excellent in 12, good in 14, fair in five and poor in three patients. Pain relief was a constant feature in all patients. Seventeen patients reported improvement in their ability to squat and sit cross-legged, 14 patients reported no change while three reported a worsening. Preoperatively 28 patients had an antalgic gait which improved in 14 patients following the surgery. Centre edge angle, acetabular angle, acetabular head index and weight bearing joint space improved significantly. This improved joint space was maintained at the last follow-up. Three cases had converted to total hip arthroplasty at the last follow-up. CONCLUSION: The mid-term functional and radiological results of the dome osteotomy using modified trochanteric osteotomy were found to be satisfactory. We conclude that it is a reasonable treatment option for young patients with symptomatic acetabular dysplasia.