Cage Augmentation of the Retained Acetabular Shell with a Dual Mobility Cup using the Double Socket Technique.

Introduction: Prevention of dislocation after total hip arthroplasty (THA) remains a topic of debate. There are various surgical options to manage hip instability such as large femoral heads, and constrained liners, although the best option to tackle this is still controversial. In revision scenarios with previous well-fixed acetabulum shells, the cementation of polyethylene liners or the cementation of dual mobility (DM) into a well-fixed acetabulum shell (Double Socket Technique) has been documented before.Here, we report a case of re-revision THA, where we have used the Double Socket Technique of retaining the previous well-fixed acetabular shell with the cementation of the DM cup along with an anti-protrusio cage inside the socket. To the best of our knowledge, this is the first such a case to be reported worldwide. Case Report: A 54-year-old male who underwent THA in 1990 and an acetabulum cup revision in 2003 presented to us with right hip pain. Radiographs showed Paprosky Type 3A femoral bone loss and polyethylene wear. Intraoperatively after removing the polyethylene liner, the acetabulum shell was found to be well fixed and therefore retained. To increase stability, an anti-protrusio cage was inserted over it and a DM cup was cemented onto it (double socket). The femoral stem was revised using Wagner stem and encerclage wires and a hook plate was used to stabilize the osteotomy site. Conclusion: This technique is a reliable option and helps shorten the surgical time and reduce the bone loss that can occur in extracting a well-fixed acetabulum shell. The use of a DM cup decreases the chances of instability compared to the cementation of polyethylene liners and decreases the high failure rate associated with the use of cementation of constrained liners. The addition of an anti-protrusio cage in addition to the Double Socket Technique increases the stability of the construct.

Bisphosphonates for Post-COVID Osteonecrosis of the Femoral Head: Medical Management of a Surgical Condition.

COVID-19 infection can cause long-term effects, cumulatively known as long COVID syndrome. One such sequela is osteonecrosis of the femoral head (also called avascular necrosis of the femoral head, or AVNFH). On the basis of our 20-year experience in using bisphosphonate therapy in the successful management of osteonecrosis, we conducted the present study to evaluate the efficacy of the therapy in the management of post-COVID osteonecrosis of the femoral head. In addition, we aimed to evaluate the cumulative dosage of corticosteroids and the duration between the commencement of corticosteroids and the development of osteonecrosis in COVID-19 survivors. Methods: This was a retrospective evaluation of 48 patients (88 hips) diagnosed with osteonecrosis of the femoral head at a tertiary care center after COVID-19 infection between September 2020 and May 2021. Patients received intravenous zoledronic acid (5 mg) at the initiation of therapy and oral alendronate (35 mg) twice weekly, and were followed for a minimum of 6 months. Clinical evaluation was conducted using a visual analog scale (VAS) for pain and the Harris hip score (HHS). Radiographic evaluation was performed to assess the progression of the disease and collapse of the femoral head. Results: At a mean follow-up of 10 months, 84 (95.5%) of the hips showed good clinical outcomes, and only 4 (4.5%) of the hips required surgical intervention. The mean VAS pain score and HHS improved at 6 weeks and steadily improved on subsequent follow-ups. In 16 (18%) of the 88 affected hips, radiographic progression was observed. The mean dose of corticosteroids administered to the patients to manage COVID-19 infection was 841.3 mg of prednisolone equivalents. The mean duration between the commencement of corticosteroid therapy and the development of osteonecrosis was 179 days. Conclusions: Post-COVID osteonecrosis appears to be more aggressive, with COVID-19 itself contributing to its etiopathogenesis in addition to corticosteroids. However, it can be diagnosed by magnetic resonance imaging (MRI) in symptomatic patients and then effectively treated medically, especially if detected in the early stages. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Secondary osteonecrosis of the knee as a part of long COVID-19 syndrome: a case series.

COVID-19 infection affects different organ systems with long-term sequelae, which has been termed as long COVID-19 syndrome. To the best of our knowledge, osteonecrosis of the knee as a part of long COVID-19 syndrome has not been documented. Corticosteroids are being used extensively in moderate and severe cases of COVID-19. We report two cases who developed osteonecrosis of the knee after being treated for COVID-19 infection. In our case series, the mean cumulative dose of prednisolone was 1156.5 mg (900-1413 mg), which is less than the cumulative dose reported in literature for osteonecrosis of the knee. In our case series, the patients developed symptomatic osteonecrosis at a mean interval of 73 days after initiation of steroid therapy, with the earliest presenting at 25 days. Early diagnosis of osteonecrosis of the knee on high clinical suspicion by MRI would help in early intervention with bisphosphonate therapy.

A Paradigm Shift in Osteonecrosis Treatment with Bisphosphonates: A 20-Year Study.

BACKGROUND: Bisphosphonates are proven to be effective in obviating the need for surgical intervention in osteonecrosis of the femoral head. However, the late onset of pain relief hampers compliance. We present the clinical and radiographic outcome of a combination therapy compared with alendronate-only therapy for the management of osteonecrosis of the femoral head. METHODS: The data of patients diagnosed with osteonecrosis of the femoral head from January 2001 to January 2017 were retrospectively analyzed. The first group, the alendronate treatment group, comprised 432 hips (358 patients) diagnosed from January 2001 to January 2009 and treated with 10-mg oral alendronate daily for 3 years. The second group, the combination treatment group, comprised 442 hips (386 patients) diagnosed from February 2009 to January 2017 and treated with a combination therapy of 35-mg oral alendronate twice weekly and 5-mg intravenous zoledronic acid once annually for 3 years. Clinical assessment was performed using the Harris hip score, the visual analog scale (VAS) pain score, and the clinical failure rate. Radiographic assessment was performed for progression and collapse. RESULTS: In the alendronate treatment group, at a mean follow-up of 129.6 months (range, 60 to 220 months), 74.5% did not require a surgical procedure, and, in the combination treatment group, at a mean follow-up of 69 months (range, 37 to 105 months), 88.9% did not require a surgical procedure. The clinical failure rate at 3 years was 4% for stage I, 11% for stage II, and 29% for stage III in the alendronate treatment group, and it was 5% for stage I, 9% for stage II, and 32% for stage III in the combination treatment group. Patients in the combination treatment group had a significantly better improvement in VAS score at 6 weeks (from 7.10 to 3.66) compared with patients in the alendronate treatment group (from 7.93 to 7.00). CONCLUSIONS: Our study shows that both oral alendronate-only therapy and bisphosphonate combination therapy retard the progression of disease, reduce the rate of collapse, and, hence, reduce the need for joint replacement surgery. However, bisphosphonate combination therapy offers earlier improvement in pain and functional scores compared with oral alendronate therapy only. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictive factors affecting long-term survivorship of ASR metal-on-metal total hip arthroplasty.

INTRODUCTION: We present the outcome of 154 ASR (Articular Surface Replacement) hips performed at the P.D Hinduja Hospital and Medical Research Centre in terms of revision rate, metal ion levels, and factors affecting survivorship. Further, determined the importance of serial metal ion estimation over single value with poorly functioning arthroplasties. METHODS: A retrospective study of 154 ASR arthroplasties (136 patients) performed from April 2005 till March 2010 was conducted. Ninety-seven patients were available for final analysis. All patients were assessed for symptoms, radiographs, blood metal (chromium and cobalt), metal artefact reduction sequence (MARS), magnetic resonance imaging (MRI), and computerized tomography (CT). RESULTS: Female gender, smaller femoral head, patients with a rising level of metal ion levels were more likely to have revision surgery. However, abnormal acetabular inclination/anteversion was not associated with the occurrence of raised metal ion levels, ARMD (adverse reaction to metal debris) or revision surgery. Patients with raised metal ion levels were more likely to have periprosthetic lucency, ARMD, and revision surgery. Median metal levels increased initially for the first three years. Still, patients who required revision surgery continued to have a metal ion rise until the point when revision surgery was performed. In contrast, patients who had a fall in metal ion levels did not require revision. CONCLUSION: A single metal ion value is less predictive of failing arthroplasties; instead, a rising trend of metal ion levels can better delineate arthroplasties which will require revision. ASR hips whose blood ion levels fell after an initial rise and showed a declining trend did well.

Superior functional outcome with dual mobility THR as compared to conventional THR in fracture neck femur: a prospective cohort study.

INTRODUCTION: Total Hip Replacement (THR) in displaced Fracture Neck of Femur (FNOF) is associated with higher dislocation rates. Conventional THR with a large femoral head and anterior approach has reduced the instability, but it remains higher than THR done for other aetiology. Recent studies have shown reduced dislocation rates with dual mobility THR (DMTHR) for FNOF; however, there is a lack of comparative research to show its superiority over conventional THR. Further, its role in the Asian subcontinent, where the patient requires sitting cross-legged or squatting, has not been studied. METHODS: A prospective cohort study of 103 elderly patients with displaced FNOF with a minimum follow-up of 1-year. Fifty-two patients were operated on with DMTHR and fifty-one patients with conventional THR. Both the groups were matched in terms of demographic data, surgical approach, and postoperative protocol. Radiological and functional outcomes in terms of Harris Hip Score (HHS), Range of motion, Patient Reported Outcome Measures (PROM), and Dislocation rate were compared between the two groups. RESULTS: Mean HHS of the DMTHR group was 76.37 at three months and 87.02 at the end of the 1-year postoperatively, which was significantly better than the conventional THR group 65.65 at three months and 72.96 at 1-year. The range of motion was significantly better in the DMTHR group than the conventional THR group. There was no significant difference in radiological outcomes and postoperative dislocation rate between the two groups. CONCLUSION: Dual mobility implants give better results than conventional implants for primary THA in elderly patients of displaced FNOF regarding better function and greater range of motion.

Avascular necrosis as a part of 'long COVID-19'.

'Long COVID-19' can affect different body systems. At present, avascular necrosis (AVN) as a sequalae of 'long COVID-19' has yet not been documented. By large-scale use of life-saving corticosteroids in COVID-19 cases, we anticipate that there will be a resurgence of AVN cases. We report a series of three cases in which patients developed AVN of the femoral head after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 758 mg (400-1250 mg), which is less than the mean cumulative dose of around 2000 mg steroid, documented in the literature as causative for AVN. Patients were symptomatic and developed early AVN presentation at a mean of 58 days after COVID-19 diagnosis as compared with the literature which shows that it generally takes 6 months to 1 year to develop AVN post steroid exposure.

Oligoanalgesia in the emergency setting - An Indian review.

Pain is a result of nociceptive tissue injury and results in acute and chronic impact to patients. Acute pain management is the need of the hour as untreated or under-treated pain may progress to chronic pain. Pain irrespective of its temporality causes a negative impact on the quality of life of the patients. Many Indian emergency settings are not adequately equipped to handle pain due to the heavy load of patients and the lack of awareness about the pain management guidelines. This leads to undertreatment of pain or 'oligoanalgesia'. A pain management protocol can help prevent oligoanalgesia in an emergency setting. Proper utilization of triage systems that incorporate pain as one of the vital signs is necessary. The categorization of pain with the help of a pain scale helps determine the severity of pain and its appropriate management. Pain management is an ongoing process that does not end with the discharge of the patient. Post discharge management of pain is also an important factor to prevent chronic pain. This may involve various modalities for pain management under the preview of multimodal management of pain.

Dual mobility THR: Resolving instability and providing near normal range of movement.

BACKGROUND: Dislocation is a common complication of Total Hip Replacement (THR), particularly when performed in primary (indications with increased risk of instability) and in revision scenarios. Dual mobility THR (DMTHR) minimizes the risk of instability in such scenarios, however most of the evidence is from western literature. Results of DMTHR in Indian scenarios where patient want to go back to their normal routine activities of squatting and sitting cross-legged is lacking. The aim of our study was to evaluate the short to mid-term results of DMTHR for varied indications (both primary and revision) in Indian scenario. To evaluate the outcome of the DMTHR in terms of functional range of motion and the ability to go back to their pre-injury level of activity. METHODS: This is a retrospective study of 150 patients operated with DMTHR between January 2015 to February 2019 with a minimum follow-up of 12 months. Patients were evaluated clinically using Modified Harris Hip Score (HHS), Range of Motion (ROM), and Patient Reported Outcome Measures (PROM) like ability to squat and sit cross legged. Radiological evaluation was done using radiographs to assess loosening, stress shielding, osteolysis. RESULTS: Mean follow up in our study was 25.2 months (Range 12-46 months). Mean Modified HHS was 71.8 ± 8.11 at 6 weeks post-op and 85.8 ± 7.62 at last follow-up. HHS showed excellent outcome in 36 hips (26.7%), good outcome in 76 hips (56.7%), fair outcome in 20 hips (14.6%), poor outcome in 3 hips (2%). All our patients were allowed to squat and sit cross-legged at a mean follow-up period of 13 weeks (8 weeks-20 weeks) except 10 cases of Revision THR where patients were advised not to squat or sit cross-legged. All patients were able to resume their activities of daily living. CONCLUSION: DMTHR in patients of all ages has shown a good short to midterm clinical outcome which is comparable to conventional THR. It confers the benefit of stability allowing our patients to squat and sit cross legged which is often one of the expectation and requirement of a patient undergoing THR in India. DMTHR in both primary and revision scenarios exhibit a low risk of dislocation, complications and revision surgery.

Repurposing denosumab for recalcitrant bone healing.

Fracture healing has four phases: haematoma formation, soft callus, hard callus and remodelling. Often, non-healing fractures have an arrest of one of these phases, which need resurgery. We have repurposed denosumab for impaired fracture healing cases to avoid surgical intervention. Here, we report a series of three cases of impaired fracture healing where denosumab was given 120 mg subcutaneous dosages for 3 months to enhance healing. All the three cases have shown complete bone union at a mean follow-up of 6.7 months (5-9 months) as assessed clinically and radiologically, and have observed no adverse effect of the therapy. Denosumab given in this dose aids fracture healing by increasing callus volume, density and bridges the fracture gap in recalcitrant fracture healing cases where the callus fails to consolidate.

Is obesity a contraindication for simultaneous bilateral total knee arthroplasty? A prospective case-control study.

AIM: Total Knee Arthroplasty (TKA) for decades has been an effective treatment modality for chronic arthritis of the knee. However, there is scarcity of literature comparing the functional outcomes of simultaneous bilateral TKA in obese patients with non-obese Indian population. We conducted this study to evaluate the functional outcomes and complication rates of simultaneous bilateral TKA in obese patients matched control with non-obese patients. MATERIALS AND METHODS: We divided the patients into two study groups based on their body mass index (BMI). Patients with a BMI of less than 30 were classified as non-obese and those with a BMI of more than 30 were classified as obese. All the patients underwent simultaneous bilateral TKA by a single surgeon using the same implant and technique. Patients were followed up regularly and functional outcomes in terms of Oxford knee score were noted at 6 weeks, 3 months, and 1 year. Post-operative complications and time to recovery was also compared. RESULTS: Mean follow-up in obese group was 18 months (12-25 months) and in non-obese group was 17 months (12-24 months). Both the groups were matched with control in terms of pre-operative parameters. Post-operative hemoglobin drop, ICU requirement, length of hospital stay, mean walking time, and mean time to climbing stairs were similar in both the groups. Oxford knee score was significantly better in non-obese group at 6 weeks, but was similar in both the groups at 3 months, 6 months, 1 year, and last follow-up. There was no statistically significant difference seen in the complication rate in both the groups. There was no implant loosening or radiolucency seen. CONCLUSION: We conclude in our study that simultaneous bilateral TKA gives comparable mid-term results in obese patients in comparison to the non-obese patients.

Incorporation of screwless press-fit acetabular cups and disappearance of polar gaps.

BACKGROUND: Uncemented press-fit acetabular cups without screws rely on the elastic recoil of the bone for its primary stability and tend to leave polar gaps with its use. The clinical significance of these gaps and the functional outcome of the patients with polar gaps is evaluated in this study. METHODS: This comparative analysis was done on 224 cementless primary THA using Deltamotion® Hip System from January 2010 to December 2017. Patients were divided into two groups based on the presence or absence of polar gaps on immediate post-operative radiographs. Patients were observed for their clinical, radiological and functional outcomes with regular follow ups. At each follow-up, patients' clinical outcome was evaluated using the Harris Hip Score (HHS) and Patient Reported Outcome Measures (PROMs). RESULTS: 14 of 224 patients(6.25%) demonstrated polar gaps in their immediate post-operative radiographs. No statistically significant difference was noted in the final mean HHS between the two groups. The polar gaps ranged from 0.5 to 1.8 mm (mean-1.09 mm). None of the patients showed progression of the polar gaps. All patients showed bony ingrowth into the gaps at a mean of 8.57 months. CONCLUSION: The presence of polar gaps in the immediate post-operative radiographs are not of a major clinical significance provided a secure peripheral fit is achieved intra-operatively. The functional outcome and rehabilitation in such patients is at par with that seen in the patients without polar gaps. Disappearance of these polar gaps is a rule rather than an exception.

Is obesity A contra-indication for a successful total knee arthroplasty?

BACKGROUND: Total Knee Arthroplasty (TKA) is one of the most effective treatment modalities for chronic knee pain and disability. A strong association exists between obesity and early knee osteoarthritis. Various studies on outcomes of TKA in obese patients have been inconclusive. The purpose of this retrospective evaluation is to assess the influence of obesity on outcomes of TKA in Indian patients. METHODS: This retrospective study conducted from 2010 to 2016 included 402 knees in 213 patients with Body Mass Index (BMI) between 30 and 39.99 kg/m2 followed up for a minimum of 12 months. All cases of revision TKAs and those with follow up less than a year were excluded from the study. Patients were followed up regularly for examining their wound healing, post operative complications if any and knee range of motion. Regular radiographs were taken to observe any evidence of loosening. Post-operative knee society scores(KSS) were recorded at each follow up. Improvement in the scores and activity level was noted. RESULTS: The objective KSS improved from 55.88 to 93.01 at the last follow up while the functional scores improved from 52.91 to 80.63. Post surgery improvement in activity level was seen in 71.83% patients. Complications seen in the study included patello-femoral pain, superficial wound infections, deep vein thrombosis and delayed wound healing. No cases of deep infection or revision surgeries were seen in our series. CONCLUSIONS: The outcome of TKA in non-morbidly obese patients is comparable to non-obese patients with excellent post-operative objective and functional scores. The benefits are sustainable over a long duration of time. The complication rates in obese patients is no different than non-obese patients.

TFNA Implant Failure with Helical Blade Cut-out.

INTRODUCTION: Trochanteric femoral nail-advanced (TFNA) was introduced in the market with better nail design, better alloy (titanium molybdenum) and both sliding and static locking options of the helical blade. Although, it was devised to overcome the shortcomings of roximal Femoral Nail Anti-rotation (PFNA), it still can have complications, if the principles of fracture management are not met. Here, we report a case of a TFNA implant failure with helical blade cut-out in an elderly osteoporotic patient treated for inter-trochanteric femur fracture. To the best of our knowledge, this is the first report of helical blade cut-out wit TFNA nail in world literature. CASE REPORT: An 83-year-old female patient was treated with a TFNA nail for inter-trochanteric femur fracture (AO 31A2.1). An acceptable reduction and stable fixation were achieved. The position of the helical blade in the head was in the optimal position with a tip apex distance (TAD) of 29 mm. The patient presented to us 6 weeks later with implant failure with helical blade cut out after a history of fall. Cemented bipolar hemiarthroplasty with calcar reconstruction using a mesh was done. The patient was clinically asymptomatic and was walking full weight-bearing till her last follow-up at 14 months. CONCLUSION: We can associate the failure seen in our case with an increased TAD of 29 mm, osteoporotic bone and a neutral to negative variance. Helical blade cut-out was seen as the blade was locked onto the nail with insufficient hold onto the osteoporotic head fragment which collapsed into varus, leading to cut-out. This case report emphasizes the importance of TAD, valgus reduction, and positive variance in avoiding implant failures, even with a newer implant like TFNA which was developed to improvise onto the shortcomings of PFNA nail.

"Floating knee," an Uncommon Injury: Analysis of 12 Cases.

OBJECTIVE: Floating knee injuries are complex injuries and are usually caused by high-velocity trauma. These injuries are often associated with life treating injuries, which should take precedent over extremity injuries. The authors reviewed the outcomes of floating knee injuries managed in this institute from 2003 to 2015. METHOD: A retrospective study was conducted of all patients with floating knee injuries from2003 to 2015. Twelve patients were included in the study. Data related to fracture type, associated injuries, treatment modalities, and complications were noted. Functional assessment was performed using the modified Karlstrom and Olerud criteria after complete bony union. RESULT: The mechanism of injury was motor vehicle accident in all patients. The mean follow up was four years. The mean age of patients was 34.75 year. The mean union time was 6.5 months in femurs and 6.7 month in tibias. The complications were knee stiffness, delayed union, and infection. According to modified Karlstrom criteria, there were three - excellent, five - good, three - fair, and one poor result. CONCLUSION: Floating knee injuries are severe injuries and are usually associated with multi-organ injuries. Early detection and appropriate management of associated injuries, early fixation of fractures, and postoperative rehabilitation are needed for good outcome. Complications are frequent, in the form of delayed union, knee stiffness, and infection.

Single Dose Therapy of Zoledronic Acid for the Treatment of Transient Osteoporosis of Hip.

OBJECTIVE: To shorten the natural course of transient osteoporosis of hip (TOH), which is a self-limiting idiopathic condition and requires 6-12 months for the resolution of symptoms, various therapies including treatment with bisphosphonates have been attempted. There exist fewer case reports evaluating the effect of bisphosphonates in TOH and most of them lack radiographic evidence of resolution of disease. The present study was carried out with an aim to evaluate the clinical and radiological outcomes of TOH patients subsequent to treatment with a single dose of zoledronic acid. METHODS: Data of 19 adult male and non-pregnant female patients with TOH treated with zoledronic acid were included in the study. Efficacy was assessed using changes in clinical signs and symptoms, visual analogue scale pain score, and changes in bone marrow edema (BME) in magnetic resonance imaging (MRI). RESULTS: Mean age of the patients was 42.1 years, 17 being males. The mean time of onset of symptom was 4 weeks. Subsequent to treatment, the patients were pain-free and had no limp within an average of 2.8 weeks (range, 2-5 weeks) and remained asymptomatic at a mean follow-up of 35 months (range, 6-54 months). The post-treatment MRI showed resolution of BME in approximately 84% (16/19) of patients at 3 months. No major adverse events were reported. None of the patients progressed to avascular necrosis at their last follow-up. CONCLUSION: Intravenous single dose administration of zoledronic acid provides early pain relief and complete reversal of TOH. Consequently, zoledronic acid is proposed as a new paradigm in the management of TOH.

Intra- operative fractures in primary Total Knee Arthroplasty.

BACKGROUND: Intraoperative fracture during primary Total Knee Arthroplasty (TKA) is very rare and there is little literature available which has defined the possible reasons for the occurrence of these fractures. Further, no study till date has defined the various management options available to treat these fractures. This study aims to define (1) the possible reasons for different fracture patterns occurring intraoperatively, (2) the ideal management options for each type of fracture geometry, (3) whether this intraoperative complication affects the physiotherapy protocol and long term outcomes. METHODS: Out of 3168 primary TKA done between 2010 and 2017, 19 patients developed intraoperative fracture, whose data was evaluated retrospectively. Patients were assessed radiologically to determine the time to union and clinical outcomes were assessed using Knee Society Score. RESULTS: Out of the 19 intraoperative fractures, 19 were in Tibia and 4 in Femur. Majority of fractures occurred during cementing and final implantation (8 cases), followed by exposure and bone preparation (6 cases) and the least during trialing (4 cases). Out of 15 Tibia fracture, 9 fractures involved the Tibial cortex which were managed with screws (4 cases), sutures and bone cement (5 cases). Stemmed tibial component was used for all Plateau type fracture patterns (6 cases). Out of 4 distal femur fractures, condylar type fracture pattern were fixed with plates and screws (3 cases) and epicondyle avulsion with screws alone (1 case). All the cases showed union (average union time 8.9 weeks) and good KSS scores which remained till their last follow-up. None of the patient developed any other complications or required revision surgery. CONCLUSIONS: Intraoperative fracture during TKA, although rare but a significant complication which can affect the outcome, if not managed properly. We have shown methods of management for such cases, which have given excellent results.

Bisphosphonate combination therapy for non-femoral avascular necrosis.

BACKGROUND: Avascular necrosis at sites other than femoral head (AVNOFH)/Non-Femoral AVN is a rare entity. No standard of treatment still exists for treating early stages of AVNOFH with most of the cases eventually progressing to a late arthritic stage needing surgical intervention. Bisphosphonates have been shown to prevent disease progression, bone collapse, and the requirement for surgery in avascular necrosis of femoral head. The present study is conducted to evaluate the response of bisphosphonates in the non-surgical management of the early stages of AVNOFH. MATERIALS AND METHODS: Prospectively collected data of 20 patients diagnosed with an early stage of AVNOFH and treated with the combination of oral alendronate 70 mg weekly and intravenous zolendronic acid (ZA) for 1 year, between Jan 2009 to Dec 2015, was evaluated retrospectively. Clinical evaluation was done using the visual analogue scale (VAS), mean analgesic requirement, and range of motion. Radiographs and magnetic resonance imaging (MRI) were taken to classify the stage of AVN, monitor radiological collapse, and evaluate radiological progression and bone marrow edema changes. RESULTS: In our analysis of 18 patients (2 lost to follow-up), 5 patients had AVN of the humeral head, 4 patients of the talus, 3 of the lunate, and 2 each of the scaphoid, medial tibial plateau, and second metatarsal head. Pain relief with the drop in VAS score was seen at a mean duration of 4.3 weeks (range 3-13 weeks) after the start of therapy. A 50% reduction in mean analgesic requirement was achieved in the first 6 weeks (2-11 weeks). MRI showed complete resolution of BME in 13 patients at 6 months and in 17 patients (94.4%) at 1 year. Radiological collapse was seen in 6 out of 18 patients at a mean follow-up of 35.3 months (range 14-56 months). Only one out of 18 patients enrolled required surgery. CONCLUSION: A combination of oral alendronate and intravenous zolendronic acid provides a pragmatic solution to this rare entity of AVNOFH, where no standard treatment exists.

Mid-term results of an uncemented tapered femoral stem and various factors affecting survivorship.

OBJECTIVE: CLS stem is commonly used today in primary hip arthroplasty, but only a few studies have evaluated their outcome in young high demanding patients. In Indian scenario, many patients require squatting and sitting cross-legged as part of their daily activities placing excessive load on the joint. We evaluated (I) Mid-long term functional and radiological results (II) Influence of age, gender, diagnosis, stem alignment, Canal fill index (CFI) on the outcome (III) Kaplan-Meier survivorship using revision for any reason or for aseptic loosening as an endpoint. METHODS: Retrospective evaluation of 64 THA in 54 patients operated between July 2000 to July 2011 using CLS stem was done. Mean follow-up was 10.3 years (5-14.9 years) with 5 patients lost to follow-up and 4 patients died. Mean age at surgery was 46.8 years (18-78 years). RESULTS: Mean Harris hip score was 89.4 (72-100). Thigh pain was present in 4 hips which were not associated with the sizing of the stem (p = .489). Stable fixation by bony ingrowth was seen in 53 hips (96.4%) and by fibrous ingrowth in 2 cases (3.6%) with no case of loosening seen. Stress shielding was seen as Grade II in 17 hips (30.9%), Grade III in 3 hips (5.4%). Pedestal formation was seen in 9 hips (16.4%) which were statistically associated with varus alignment and CFI < 80. No stem revision was performed with stem survivorship of 100%. CONCLUSION: The mid-term survival rates and good clinical-radiological outcomes of CLS stem in high demanding Indian population were excellent.

Concealed cosmetic closure in total knee replacement surgery - A prospective audit assessing appearance and patient satisfaction.

OBJECTIVE: With the trend towards accelerated rehabilitation, the method of skin closure has become increasingly important in orthopedic surgery. It is imperative to evaluate a technique that provides superior clinical and cosmetic results specifically for TKA, due to relatively thin skin anterior to the knee making poor wound healing an issue of concern. We conducted a prospective, single-arm audit evaluating the patient assessments of incision cosmesis for a novel technique in TKA wound closure called Concealed Cosmetic Closure (CCC). METHODS: 570 knees were included in the study whose wound was closed with concealed cosmetic subcuticular interrupted sutures (CCCIS) between January 2014 and May 2016. A validated, ordinal questionnaire, Stony Brooks Scar Evaluation Scale (SBSES) designed to elicit a score evaluating scar satisfaction was interviewed by the investigators to patients 6 months to 3 years postoperatively. RESULTS: CCC is a simple and relatively rapid single-operator technique that takes about 7-10 min to close 11-17 cm knee incision. In our study, the mean score for Stony Brook Scar Evaluation Scale (SBSES) was 4.4 (SD of 0.73) (range 3-5). The scar was rated highly in terms of cosmesis, patient satisfaction and appearance of the wound. CONCLUSION: CCC is an effective modality for skin closure in total knee arthroplasty providing superior cosmetic healing with minimal complications leading to improved long term patient satisfaction.