The MCL apprehension sign: A novel test for MCL instability.

Purpose: This study describes a new clinical sign to diagnose clinically relevant medial collateral ligament (MCL) injury and evaluates its use in diagnosis and planning treatment for MCL injuries. Methods: A total of 30 consecutive patients with suspected MCL injury, visiting the sports knee clinic were screened by the senior author and the knee fellow for any clinical laxity. Of these, 9 patients did not have any clinically demonstrable laxity but did have MRI evidence of MCL injury. The presence of apprehension sign was compared against the standard criteria for MCL laxity and was evaluated as a novel test to diagnose clinically significant MCL laxity. Results: Of the 21 patients who were diagnosed to have MCL laxity, 18 had a positive apprehension sign at the time of presentation. Eight out of the nine patients who were negative for MCL laxity, did not have a demonstrable apprehension sign. According to the gold standard index, the apprehension sign had a sensitivity of 85.7% and a specificity of 88.8%. The positive and negative predictive values were 94.7% and 72.7% respectively. The pre-test probability of MCL laxity based on the diagnostic criteria was 70% and increased to 94.7% with a positive apprehension sign. Conclusions: A positive apprehension sign is suggestive of MCL injury requiring active treatment. It also helps in deciding the length of bracing required and the need for further operative treatment. The authors recommend its use as a reliable & reproducible adjunct to standard clinic-radiological work-up for MCL injuries.

Canal occlusion in cemented primary total hip replacement: autologous compacted bone block compared to a commercially available gelatine plug.

AIMS: To evaluate the stability of 2 canal occlusion systems; an autologous, compacted bone block and the biodegradable C-plug. We also sought to investigate any relationship between stability of the systems and the quality of cementation. A retrospective radiographic comparative review was conducted. METHODS: A total of 203 consecutive patients were analysed, 89 received an autologous bone block and 114 had C-plugs. There was no significant differences between the groups in terms of age, sex and primary diagnosis. The mean cement tail length in the bone block group (6.42 mm; range 0-31) was significantly shorter than in the C-plug group (17.11 mm; range 0-65.7). RESULTS: The proportion of patients with good quality of cementation (Barrack grade A) was significantly higher in the bone block group (80.6%) as compared to the C-plug group (56%) (p < 0.001). There was a negative correlation between the length of the cement tail and the Barrack grade, indicating that a short cement tail is associated with better quality cementation. CONCLUSIONS: We have shown that improved cement penetration and shorter cement tails can be achieved with the cheapest of all options for canal occlusion, an autologous compacted bone block and hence recommend this technique.

Early results of a high friction surface coated uncemented socket in revision hip arthroplasty.

BACKGROUND: Revision hip arthroplasty with high friction trabecular metal sockets has resulted in good medium-term results. Many manufacturers have therefore introduced higher friction coatings to their implants to meet a growing demand for similar implants. The Pinnacle Gription was introduced in 2007 as an evolution of the standard Pinnacle socket. This study aimed to assess the early results of this socket in a revision setting. METHODS: Between August 2009 and December 2016, the Gription socket was used in 146 revision hip replacements. The mean age was 63 (19-88) years. Defects were classified as Paprosky Grade 2 in 71(2A [28], 2B [19], 2C [24]) and grade 3 in 20 (3A [18], 3B [2]). Bearing combinations were ceramic-on-ceramic in 23, metal-on-polyethylene in 71, ceramic-on-polyethylene in 52. Screws were used in 112 cases, impaction bone grafting in 34 and metal augments in 1 case. Radiographs were analysed for progressive radiolucent lines and migration. RESULTS: Mean follow-up was 43.5 (range 25-62) months. There were 6 re-revisions (2 for deep infection, 2 for recurrent dislocation and 2 for aseptic loosening). None of the other cases had evidence of socket migration or progressive radiolucent lines. There were no intraoperative or postoperative periprosthetic fractures. The crude survivorship for all-cause failure was 95.8% and the survivorship for aseptic loosening was 98.6%. at 43.5 months follow-up. CONCLUSIONS: This is the largest reported series of Gription socket use in revision arthroplasty and demonstrates encouraging early results. We therefore advocate the continued cautious use of this implant.

A Brodie's Abscess of Femoral Neck Mimicking Osteoid Osteoma: Diagnostic Approach and Management Strategy.

BACKGROUND: Brodie's abscess usually presents as a diagnostic dilemma resulting in a diagnostic delay. It mimics various benign and malignant conditions both clinically and radiologically. CASE DETAILS: This report describes a case of a 14 year old boy who presented with a clinical and radiological picture of osteoid osteoma of proximal femur but found to have a brodie's abscess on histology and culture. CONCLUSION: It describes the clinical spectrum of subacute osteomyelitis, its unusual MRI features and the importance of obtaining a histological diagnosis before definitive treatment.

Giant Cell Tumor of Bone - An Overview.

Giant Cell tumors (GCT) are benign tumors with potential for aggressive behavior and capacity to metastasize. Although rarely lethal, benign bone tumors may be associated with a substantial disturbance of the local bony architecture that can be particularly troublesome in peri-articular locations. Its histogenesis remains unclear. It is characterized by a proliferation of mononuclear stromal cells and the presence of many multi- nucleated giant cells with homogenous distribution. There is no widely held consensus regarding the ideal treatment method selection. There are advocates of varying surgical techniques ranging from intra-lesional curettage to wide resection. As most giant cell tumors are benign and are located near a joint in young adults, several authors favor an intralesional approach that preserves anatomy of bone in lieu of resection. Although GCT is classified as a benign lesion, few patients develop progressive lung metastases with poor outcomes. Treatment is mainly surgical. Options of chemotherapy and radiotherapy are reserved for selected cases. Recent advances in the understanding of pathogenesis are essential to develop new treatments for this locally destructive primary bone tumor.

A report of nonunion at medial wedge high tibial osteotomy site and its management.

High tibial osteotomy (HTO) is an accepted treatment option for correcting deformities and reducing pain in the treatment of uni-compartment osteoarthritis of the knee. The principle is to redistribute the weight-bearing load. Medial open wedge HTO (MOWHTO) has gained popularity over lateral closed wedge osteotomy due to its decreased incidence of complications. MOWHTO surgical techniques have many variations in fixation techniques and in the use of bone grafts or bone substitute augmentation. In spite of the existing guidelines, there are no clear indications of grafting at the osteotomy site. Delayed union and nonunion although are possible complications, nonunion is especially rarely reported. Thus authors in this case report, like to point attention towards this under-reported complication and its management.

A novel technique of patella fracture fixation facilitating early mobilization and reducing re-operation rates.

OBJECTIVE: Fractures of patella constitute 1% of all fractures. Various techniques have been described for internal fixation of patella fractures. Superiority of one technique over the other has long been debated. We reviewed a series of fifty-one patients with transverse or comminuted fractures of patella treated with a novel technique to assess if it had any advantages over the existing methods of fixation. DESIGN: Retrospective. SETTING: A tertiary care centre. PATIENTS & METHODS: Fifty-one patients with patella fracture OTA 34C, with a mean age of 39 years (range 18-61) were treated with technique of cerclage and two tension bands at our institute. Forty-eight patients completed the study. MAIN OUTCOME MEASUREMENTS: Range of Motion and evidence of radiological union were assessed at regular follow-ups. RESULTS: Forty-four out of forty-eight patients had gained up-to 90 degrees of active flexion at the end of 1 week. Two patients (4.2%) developed superficial infection. All fractures had united at the end of 12 weeks. Five patients (10.3%) underwent a second surgery; four (8.3%) due to implant related complications. Malunion or non-union was not noted in any of the cases. CONCLUSION: The advantages of the described method are early mobilization, elimination of k-wire related complications, and ease of use in comminuted fracture pattern as well and a lower reoperation rates as compared to the available literature. We strongly recommend its use in cases of displaced comminuted/transverse fractures of patella as an alternate method of treatment. LEVEL OF EVIDENCE: Level III.

A rare case of giant cell tumour arising from anterior cruciate ligament: Its diagnosis and management.

Tenosynovial giant cell tumour is a locally aggressive tumour arising from the synovia of the fibrous tissue surrounding the joints, tendon sheaths and tendons. Areas of predilection are the hand, and in the case of synovial joints, the knee joint is particularly affected. We describe a rare case of an intra-articular localized tenosynovial giant cell tumour arising from the anterior cruciate ligament (ACL) in a 27 year male who presented with pain and giving way of his left knee without prior history of any trauma. Tests for internal derangement of knee were negative. MRI reported an ACL tear with a heterogeneous fibrous mass attached to the distal part, most probably an organized haematoma. It was decided to do a diagnostic arthroscopy before proceeding for ACL reconstruction. Arthroscopy revealed a purple coloured mass attached to distal part of ACL. The mass was removed piecemeal using an additional posterolateral portal. ACL was found intact. Histopathology reported it to be tenosynovial giant cell tumour. The patient was asymptomatic at each subsequent follow up. It is a rare diagnosis which presented as an ACL tear; in such suspected cases it is prudent to perform a diagnostic arthroscopy before going for ACL reconstruction.