Expert Consensus on Dipeptidyl Peptidase-4 Inhibitor-Based Therapies in the Modern Era of Type 2 Diabetes Mellitus Management in India.

India has a high prevalence of type 2 diabetes mellitus (T2DM) with unique clinical characteristics compared to other populations. Despite advancements in diabetes therapy, a significant number of patients in India still experience poor glycemic control and complications. Dipeptidyl peptidase-4 (DPP-4) inhibitors continue to be an important component of T2DM treatment due to their favorable efficacy and tolerability profile. Given the current scenario, there is a need to revisit the role of DPP-4 inhibitors in T2DM management in Indian patients. This consensus paper aims to provide guidance on the utilization of DPP-4 inhibitors in T2DM management from an Indian perspective. A consensus group of 100 experts developed recommendations based on an extensive literature review and discussions. The expert group emphasized the importance of timely glycemic control, combination therapy, and targeting the underlying pathophysiology of T2DM. The combinations of DPP-4 inhibitors with metformin and/or sodium-glucose transport protein-2 inhibitors are rationalized in this paper, considering their complementary mechanisms of action. This paper provides valuable insights for clinicians in optimizing the management of T2DM in the Indian population with the use of DPP-4 inhibitors and proposes an algorithm for selecting DPP-4 inhibitor-based therapies.

Incidence of Soft-Tissue Releases, Clinical and Radiological Outcomes of Lateral Parapatellar Approach for Valgus Arthritic Knees: A 4-year Follow-up Study with A Review of Literature.

PURPOSE: To analyse the incidence of additional soft tissue releases with the lateral parapatellar approach, and the clinical and radiological outcomes of total knee arthroplasties performed using the lateral parapatellar approach for valgus arthritic knees. A review of the existing literature on valgus arthritic knees undergoing knee replacement was performed and our results compared. MATERIALS AND METHODS: This is a prospective cohort study of 50 patients operated by this approach. Operation and clinical records were assessed to determine the number and sequence of soft tissue releases. Functional outcome was measured using the Oxford Knee Score. Radiological assessment included measurement of alignment and implant positioning. RESULTS: 46 patients included. Mean follow-up of 4 years. Additional lateral releases were performed in 11 (24%) cases. Mean valgus alignment corrected from 13.1 degrees pre-operatively to 5.7 degrees post-operatively. Oxford Knee Score improved from a mean pre-operative score of 11.9 to a mean post-operative score of 38.3 at final follow-up. Radiographs revealed lateralisation of the tibial component in 4 patients. No immediate or late post-operative wound complications, late instabilities or revisions were observed. CONCLUSION: Lateral parapatellar approach is highly effective in correcting the valgus deformity with a low incidence of additional soft tissue releases. Medium-term results indicate an excellent functional outcome with no complications.

Operative versus conservative treatment of proximal rectus femoris avulsions: A systematic review with meta-analysis of clinical outcomes, complications and return to sports.

PROSPERO REGISTRATION NUMBER: CRD42020198333. OBJECTIVE: To compare the surgical and conservative treatment of proximal rectus femoris avulsions regarding clinical outcomes, rate of return to sports and incidence of complications. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Cochrane, Medline, Scopus and SPORTDiscus. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies reporting on outcomes of PRFAs or return to sports were included. RESULTS: Nine studies consisting of a total eighty-two patients met the inclusion criteria. The mean age was 22.2 years and 75.9% of patients were male. Mean follow-up was 28.9 months and 65% avulsions were managed surgically. The overall outcomes were similar in surgical and conservative treatment group (p = 0.72) with similar incidence of complications (14%). The rate of return to sports was 95% in surgical and 92.7% in the conservative management groups (p = 0.93). Overall, the quality of the methodology of included studies was low, with a mean CMS of 45.6. CONCLUSION: Both conservative and operative treatment provide excellent outcomes in proximal rectus femoris avulsions, with similar rates of return to sports and incidence of complications. More prospective and good quality studies are needed to compare surgical techniques and time to return to sports. Avulsions with retraction of more than 20 mm and high demand patients may benefit from surgical treatment. Patients should be counselled accordingly.

Recurrent patellar dislocations with patellar cartilage defects: A pain in the knee?

BACKGROUND: Recurrent patellar dislocation in combination with cartilage injures are difficult injuries to treat with confounding pathways of treatment. The aim of this study was to compare the clinical and functional outcomes of patients operated for patellofemoral instability with and without cartilage defects. METHODS: Eighty-two patients (mean age 28.8 years) with recurrent patellar dislocations, who underwent soft-tissue or bony procedures, were divided into two matched groups (age, sex, follow up and type of procedure) of 41 each, based on the presence or absence of cartilage defects in patella. Chondroplasty, microfracture, osteochondral fixation or autologous matrix-induced chondrogenesis (AMIC)-type procedures were performed depending on the nature of cartilage injury. Lysholm, Kujala, Tegner and Subjective Knee scores of both groups were compared and analysed. Complications and return to surgery were noted. RESULTS: With a mean follow up of 8 years, there was a significant improvement observed in all the mean postoperative patient-reported outcome measures of both groups, as compared with the preoperative scores (P < 0.05). Comparing the two groups, postoperative Lysholm, Kujala and Subjective knee scores were significantly higher in patients operated without cartilage defects (P < 0.05). Three patients operated for patellofemoral instability with cartilage defects underwent patellofemoral replacement subsequently. The odds ratio for developing complications was 2.53 for patients operated with cartilage defects. CONCLUSION: Although there is a significant improvement in the long-term outcome scores of patients operated for recurrent patellar dislocation with cartilage defects, the results are significantly inferior compared with those without cartilage defects, along with a higher risk of developing complications and returning to surgery.

Clinical outcomes of primary anatomic all-inside Anterior Cruciate Ligament reconstruction using the TransLateral technique: A minimum one-year follow-up study.

BACKGROUND: Anatomic all-inside Anterior Cruciate Ligament (ACL) reconstruction using the TransLateral technique is relatively new. This technique utilises single tendon autograft and instruments permitting inside-to-out drilling to create retrograde sockets. Few studies have investigated clinical outcomes following this technique. We investigate clinical outcomes in patients who underwent primary anatomic all-inside ACL reconstruction using the TransLateral technique with a minimum one-year follow-up. METHODS: Interrogation of our prospectively maintained database identified patients who underwent surgery from June 2013 to December 2017. Patients were followed up clinically and using patient-reported outcome measures (PROMS) including EQ-5D, KOOS, IKDC and Tegner scores from the National Ligament Registry. Paired two-tailed Student t-test was used to assess for clinical significance. RESULTS: One hundred forty-one cases with a mean age of 30 years (range 16.0-60.2) and mean follow-up of 17.4 months (12.1-75.2) were included. Grafts included isolated quadrupled semitendinosus (n = 115) and both quadrupled semitendinosus and gracilis (n = 26). One hundred and two patients (72.3%) had complete peri-operative PROMS. Mean increases in EQ-5D VAS and IKDC scores were 18.9 and 29.2 points (p < 0.001). Significant peri-operative improvements were observed for all KOOS domains (p < 0.001). Median Tegner activity score increased by two levels (p < 0.001). Incidence of graft re-rupture was 5.7% (n = 8), all were following significant knee trauma and seven cases were mid-bundle femoral tunnel placements. CONCLUSIONS: All-inside ACL reconstruction using the TransLateral technique demonstrates good clinical and functional outcomes with low complication and failure rate. Mid-bundle femoral tunnel placements have been abandoned in favour of placement deep within the anteromedial bundle footprint.

Targeted computerised tomography scanning of the ankle syndesmosis with low dose radiation exposure.

OBJECTIVES: To devise a new protocol for targeted CTscanning of the distal tibiofibular syndesmosis with minimal radiation exposure to patients. We also aimed to correlate the reduction of the syndesmosis as seen on CT scans with the functional outcome of patients. MATERIALS AND METHODS: Prospective study. Forty adults undergoing surgical stabilisation of an acute distal tibiofibular syndesmosis injury were recruited. A targeted five-cut computerised tomography scan protocol was developed. The radiation exposure to the patient with this protocol was only 0.002 mSv. Scans were performed 12 weeks after surgery. The contralateral ankle of every patient was used as a control to determine the accuracy of the reduction of the syndesmosis for that individual patient. American Orthopaedic Foot and Ankle Society (AOFAS) scores were obtained at a minimum of 1 year after surgery. RESULTS: After considering the exclusions, 36 patients formed the study group. A wide variation was observed in the anatomy of the normal syndesmosis. If we considered a difference of more than 2 mm between the normal and injured syndesmosis relationship as significant, 15 (41.6 %) of our patients had a significant difference between the injured and normal sides. AOFAS scores were available for 13 of these patients and were good to excellent in 11(84.6 %). CONCLUSION: Our study describes a reliable new CT scanning technique for the distal tibiofibular syndesmosis using only five cuts and a low-radiation-dose protocol. Clinical correlation of the findings on the scan with functional outcomes suggests that routine post-operative CT of the syndesmosis is probably not justified.

Management of Mason type 1 radial head fractures: a regional survey and a review of literature.

INTRODUCTION: Despite being the most common fracture around the elbow, the management of Mason type 1 radial head fractures lacks a clear protocol in literature. The aims of this study were to assess our practice of managing this injury and to create guidance for the management of these fractures based on literature review. METHODS: We designed a survey investigating the practice of orthopaedic surgeons in the management of Mason type 1 fracture. The literature review was carried out looking for the best practice guidelines. RESULTS: Forty-nine surgeons (out of 56) responded, and mean duration of immobilisation was 11.69 days with the collar and cuff sling as the preferred method. 65.3% offered physiotherapy service to their patients. 20.4% recommended plain radiographic imaging follow-up. Mean duration of follow-up was 43.9 days. Decision to discharge the patient was mostly (77.6%) dependent on clinical improvement at time of last examination. 4.1% of treatment decisions were evidence based. CONCLUSION: We observed a wide variation in the management of this common injury. Based on the current literature, the best protocol for the management of type 1 radial head fractures should be joint aspiration, followed by immobilisation in a broad arm sling for 2 days. At the first outpatient visit, assessment of the collateral stability should be performed. Patients with stable elbows should be encouraged to stretch these beyond the painful range. Patients can be discharged at this stage with an advice to come back for a clinical and radiographic assessment if there is no improvement at 6 weeks.

Urinary retention following lower limb arthroplasty: analysis of predictive factors and review of literature.

Acute urinary retention is a common complication after lower limb arthroplasty. The aim of our study was to assess whether the International Prostate Symptom Score (IPSS) and other patient related factors could predict the likelihood of patients developing urinary retention after lower limb arthroplasty. We have also reviewed the literature on this subject. This is a prospective study of 102 male patients undergoing hip or knee arthroplasty. Data collected included age, IPSS, type of operation, type of anaesthesia and development of acute urinary retention in the immediate postoperative period. Thirty-one patients (30.4%) developed acute urinary retention. Of all the parameters studied, age was the only factor that correlated significantly with development of urinary retention. The risk factors for progression of benign prostatic hyperplasia could all be considered as factors for the development of this complication. However, apart from age more than 70 years, it is not practical to use the other parameters.

Anterior tibial artery pseudoaneurysm in a patient with hemophilia: a complication of ankle arthroscopy.

Arterial pseudoaneurysm formation as a complication of ankle arthroscopy is extremely rare. We present a case of anterior tibial artery pseudoaneurysm identified 10 days after ankle arthroscopy in a patient with hemophilia. The diagnosis was confirmed with a duplex ultrasound scan. The patient was referred to the vascular surgeon and underwent evacuation of the hematoma, resection of the damaged segment of the artery, and reconstruction with a reversed long saphenous vein interposition graft. The patient had an uneventful recovery after the second surgery. The prevention of this complication in patients with hemophilia is discussed, as well as diagnosis and management. Preventative measures include careful dissection while making the portals, preoperative mapping of the artery with a duplex or a handheld Doppler in patients with coagulopathy, and performance of open rather than arthroscopic surgery to excise large osteophytes.

Total hip replacement infected with Mycobacterium tuberculosis. A case report with review of literature.

Mycobacterium Tuberculosis infection of a total joint prosthesis in patients with previous pulmonary or osteoarticular tuberculosis is well recorded in literature. We describe the case of a 59-year-old woman with tuberculous infection complicating a total hip arthroplasty 15 months after surgery for osteoarthritis. The patient had no prior history of exposure to tuberculosis and no evidence of pulmonary or osteoarticular tuberculosis. She was treated with four-drug antituberculous chemotherapy for 12 months with retention of the prosthesis. The purpose of this case report and literature review is to highlight to the Western Orthopaedic surgeon the importance of keeping in mind a differential diagnosis of tuberculosis while dealing with prosthetic joint infections. The infection of a joint with Mycobacterium Tuberculosis in patients without previous tuberculosis is very uncommon. We have reviewed the surgical and medical management of the cases reported in literature.

A tip on using the appropriate wire passer in orthopaedic surgery.

The authors present a technical tip on using the appropriate wire passer while passing cerclage wires around long bones in orthopaedic surgery.

Disappear to appear again? Chloroma of the pelvis--a unique osseous presentation.

Osteolytic lesions caused by chloromas or extramedullary myeloid tumours have been reported before. We present a case of localised osteolysis caused by a chloroma, in which complete repair of the bony lesion occurred following chemo- and radiotherapy. We believe that this unique presentation has never been reported before in the English literature.