Putrescence to Quintessence: An Atypical Presentation of Multiple Osteoporotic Spinal Fractures Masquerading as Multiple Myeloma.

A 64-year-old male patient presented with multiple osteoporotic spinal fractures of unknown origin. He was provisionally diagnosed with multiple myeloma based on biochemical and radiological findings. The patient presented in a very frail condition with a questionable outcome but showed a remarkable recovery from being frail to relatively fit. His baseline characteristics including magnetic resonance imaging of the dorsolumbar spine, beta 2 microglobulins, and C-reactive protein improved. The diagnosis was later changed to multiple spinal osteoporotic fractures. In this case report, we highlight that, although it is a good practice to have a single working diagnosis, when the diagnosis is challenging, a holistic approach should be followed to prevent medical and diagnostic miscalculations.

Short term results of cementless total hip arthroplasty in sicklers.

BACKGROUND: Sickle cell (SC) disease leading to endarteritis induces skeletal changes in the form of osteitis, sclerosis of femoral canal and osteonecrosis of the femoral head. All these make total hip arthroplasty (THA) difficult and prolonged. There is increased risk of infection, SC crisis and increased complication rate. Our paper aims to highlight preoperative, intraoperative and postoperative hurdles encountered in performing THA in sicklers and the short term outcome using cementless implants. MATERIALS AND METHODS: Thirty-nine patients with SC disease, who had osteonecrosis of the femoral head, were operated between 2007 and 2011. The mean age of patients was 22 years (range 13-49 years). There were twenty eight females and 11 males. Bilateral cementless total hip replacement (THR) was performed in 11 patients (22 hips) and in the rest unilateral (28 hips). Preoperative and postoperative modified Harris hip score was evaluated. The average followup was 3.8 years (range 2-6 years). RESULTS: The average operating time was 96 min (range 88-148 min). The average blood loss was 880 ml (range 650-1200 ml). The average intraoperative blood transfused was 2.3 units (range 2-5 units). All patients showed an improvement in Harris hip score from 42 points preoperatively to 92 points at latest followup. Intraoperatively, one patient had a periprosthetic fracture. Six patients developed acute SC crisis and were managed in intensive care unit. Three patients developed wound hematoma. Three patients developed limb length discrepancy less than 1 cm. None had early or late dislocations, infection, heterotopic ossification, sciatic nerve palsy and aseptic loosening. CONCLUSION: THA in sicklers involves considerable challenge for the orthopedic surgeon. Management requires a multidisciplinary approach involving the anesthetist, hematologist and the orthopedic surgeon. Contrary to previous reports, THA in sicklers now has a predictable outcome especially with the use of cementless implants.

Outcome of double bundle anterior cruciate ligament reconstruction using crosspin and aperture fixation.

BACKGROUND: Double bundle anterior cruciate ligament (DBACL) reconstruction is said to reproduce the native anterior cruciate ligament (ACL) anatomy better than single bundle anterior cruciate ligament, whether it leads to better functional results is debatable. Different fixation methods have been used for DBACL reconstruction, the most common being aperture fixation on tibial side and cortical suspensory fixation on the femoral side. We present the results of DBACL reconstruction technique, wherein on the femoral side anteromedial (AM) bundle is fixed with a crosspin and aperture fixation was done for the posterolateral (PL) bundle. MATERIALS AND METHODS: Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing. METHODS: Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing. RESULTS: The KT-1000 results were evaluated using paired t test with the P value set at 0.001. At the end of 1 year, the anteroposterior side to side translation difference (KT-1000 manual maximum) showed mean improvement from 5.1 mm ± 1.5 preoperatively to 1.6 mm ± 1.2 (P < 0.001) postoperatively. The Lysholm score too showed statistically significant (P < 0.001) improvement from 52.4 ± 15.2 (range: 32-76) preoperatively to a postoperative score of 89.1 ± 3.2 (range 67-100). According to the IKDC score 90% patients had normal results (Category A and B). The AM femoral tunnel initial posterior blow out was seen in 4 patients and confluence in the intraarticular part of the femoral tunnels was seen in 6 patients intraoperatively. The quadriceps strength on isokinetic testing had an average deficit of 10.3% while the hamstrings had a 5.2% deficit at the end of 1 year as compared with the normal side. CONCLUSION: Our study revealed that the DBACL reconstruction using crosspin fixation for AM bundle and aperture fixation for PL bundle on the femoral side resulted in significant improvement in KT 1000, Lysholm and IKDC scores.

Discoid medial meniscus completely coalesced with the anterior cruciate ligament.

Discoid meniscus is an abnormality of the knee in which the meniscus is discoid rather than semilunar in shape. Medial discoid menisci are rare, and no specific associated symptoms suggest this condition. Several medial meniscus anomalies, including discoid variants, have been reported in the literature. This article describes a rare case of medial discoid meniscus completely coalesced with the anterior cruciate ligament (ACL). A 22-year-old man presented with intermittent right knee pain of 6 months' duration. Physical examination revealed mild wasting of the quadriceps with medial joint line tenderness but no effusion. Radiographically, hypoplasia of the lateral tibial spine, increased medial joint space, and increased concavity of the medial tibial condyle were noted in both knees. Arthroscopic examination revealed a complete discoid medial meniscus that was contiguous with the ACL. On probing, a horizontal tear in the medial meniscus was noted. A meniscectomy was performed, and deep longitudinal furrows with exposed subchondral bone were noted underlying the posteromedial tibial condyle. At the patient's 6-month follow-up visit, he had no knee symptoms and had returned to his daily activities, which included jogging. Discoid medial meniscus is a rare anomaly, and this case represents only the second reported in the literature of discoid medial meniscus completely coalesced with ACL. This case supports the theory that the ACL and menisci can be differentiated from 1 mesenchyme.

Effect of haemarthrosis on the rehabilitation of anterior cruciate ligament reconstruction--single bundle versus double bundle.

BACKGROUND: Haemarthrosis and pain adversely affects the functional outcome of ACL reconstruction, especially in case of DB ACL reconstruction due to more extensive procedure. The purpose of the study was to evaluate the effect of haemarthrosis on the rehabilitation of DB ACL reconstruction versus SB ACL reconstruction. METHODS: 100 patients were divided into two groups, of SB ACL and DB ACL reconstruction consisting of 50 patients each. An intra-articular drain was put in every patient. The pain was evaluated till week 8 using VAS (Visual Analog Scale). The Functional outcomes were evaluated using the Isokinetic Dynamometer at 3 and 6 months in both the groups. Muscle bulk and Range of motion were also noted in each group. RESULTS: The results showed that there was statistically significant difference between the drain amount (n=60.3 ml in SB ACL group vs. n=94.2 ml in the DB ACL group) and haemarthrosis (n=0.7 in SB ACL vs n=1.5 in DB ACL) at week 1 post-operatively. Also the pain outcome improved on SB ACL after day 3 (VAS, n=1.8) as compared to the DB ACL group (VAS, n=3.7). The isokinetic muscle strength was found to be statistically significantly (p value<0.05) better in the SB ACL group in the quadriceps muscle (both concentric and eccentric) at the end of the 3rd month. In the SB ACL group the Quadriceps Concentric strength deficit was 22.32% as compared to 34.12% in the DB ACL group. Both the groups had comparable flexor muscle strength at end of 3rd month. Both the groups had comparable muscle strength after 6 months of post-operative rehabilitation in both quadriceps and Hamstring muscle group. CONCLUSION: We noted that rehabilitation of DB ACL reconstruction group lags behind that of SB ACL reconstruction during the first 3 months due to post-operative haemarthrosis & its effects, but show comparable results after 6 months. The muscle strength measured isokinetically and the muscle bulk were found to be greater in the SB ACL group initially after 3 months but was found to be similar after 6 months.

Percutaneous tension band wiring for patellar fractures.

PURPOSE: To evaluate outcome of percutaneous tension band wiring for transverse fractures of the patella. METHODS: 16 men and 7 women aged 27 to 65 (mean, 40) years underwent percutaneous tension band wiring for transverse fractures of the patella with a displacement of >3 mm. Pain, operating time, mobility, functional score, and complications were evaluated. RESULTS: 20 patients underwent successful percutaneous tension band wiring. The remaining 3 patients in whom closed reduction failed underwent open reduction and tension band wiring. The mean operating time was 46 (range, 28-62) minutes. The mean follow-up period was 20 (range, 15-30) months. At the latest follow-up, all patients had regained full extension. The objective score was excellent in 20 patients and good in 3, whereas the subjective score was excellent in 17, good in 5, and fair in one. All patients had radiological union at week 8. One patient had patellofemoral arthritis (secondary to a postoperative articular step). Two patients developed superficial infections, which resolved after antibiotic therapy. Mean thigh muscle wasting was 0.7 (range, 0.4-1) cm. Three patients encountered hardware problems (impingement/irritation of the skin over the knee) necessitating implant removal. CONCLUSION: Percutaneous tension band wiring is a viable option for transverse fractures of the patella.