Comparison of Patellofemoral Outcomes between Attune and PFC Sigma Designs: A Prospective Matched-Pair Analysis.

BACKGROUD: Attune (DePuy Synthes) prosthesis was designed to overcome patellofemoral complications associated with PFC Sigma (DePuy Synthes) prosthesis. The aim of our study was to compare the incidence of anterior knee pain (AKP), patellofemoral crepitus (PCr), and functional outcome between them. METHODS: This prospective matched-pair study was conducted between January 2014 and June 2015, during which 75 consecutive Attune total knee arthroplasties (TKAs) were matched with 75 PFC Sigma TKAs based on age, sex, body mass index, pathology, and deformity. A single surgeon performed all the operations with aid of computer navigation, using a posterior-stabilized prosthesis with patellar resurfacing. Outcome was assessed by new Knee Society Score (NKSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. AKP and PCr were assessed by a patient-administered questionnaire till 2 years of follow-up. Three pairs were lost to follow-up and finally 72 pairs were analyzed. RESULTS: One patient in each group reported AKP and 1 patient from each group had PCr at 2 years postoperatively. None of these patients required additional surgery. The incidence of lateral retinacular release was higher with PFC Sigma (5/72) than Attune (2/72); however, this was statistically not significant (p = 0.4). The Attune group had a significantly greater range of motion (ROM) at 3 months postoperatively (p = 0.049). At final follow-up, ROM was comparable between two prosthesis designs. NKSS and WOMAC scores were also comparable between the groups. CONCLUSIONS: We observed that both Attune and PFC Sigma had a low and comparable incidence of AKP and PCr up to 2 years of follow-up. The Attune group achieved a significantly greater ROM at 3 months postoperatively. At 2 years of follow-up, both prostheses had excellent and comparable clinical and functional results.

Forgotten Joint Score Post Total Knee Arthroplasty and Its Correlation with the New Knee Society Score.

BACKGROUND/PURPOSE: Forgotten Joint Score (FJS) is designed to asses patient recovery post Total Knee Arthroplasty (TKA) in a new dimension. It assess the ability to forget the operated joint as artificial during activities of daily living. New Knee Society Score (NKSS) is developed to encompass objective and subjective outcome as well as an assessment of patient expectation and satisfaction. Our purpose was (1) to determine FJS at 1 year post TKA in Indian Patients, and (2) to assess convergent validity between FJS and the NKSS. We hypothesised that FJS should strongly correlate with the Satisfaction (SS) and Knee perception(KPS) sub-component of NKSS. METHODS: We enrolled 181 patients who underwent primary TKA during an 8-month duration. They were prospectively followed up at 1-year review clinic when FJS and NKSS were administered. 169 patients completed the assessment forms and 13 patients were lost to follow-up. Statistical evaluation was done with Spearman correlation test. RESULTS: Mean FJS at 1 year was 66.6 ± 25.9 with 14% ceiling and 1% floor effects. There was a mild to moderate correlation of FJS with NKSS (p < 0.001, r = 0.47) and its sub-scores (p < 0.001; r = 0.43 and r = 0.44). There was a weak correlation of FJS with NKSS sub-components of SS and KPS (p < 0.001; r = 0.37 and 0.25, respectively). CONCLUSION: Mean FJS at 1 year post TKA showed convergent validity with NKSS; however, the correlation was not strong enough to use them interchangeably. Hypothesis that FJS should strongly correlate with the NKSS sub-components of satisfaction and joint perception was refuted. We conclude, FJS provides unique evaluation in recovery post TKA, different from NKSS. LEVEL OF EVIDENCE: Level III.

Radial Nerve Palsy After Intercondylar Distal Humerus Fracture: A Case Report.

CASE: A 30-year-old man sustained an injury to the right elbow after a fall from a bike. On clinical examination, he had preoperative radial nerve palsy with radiological diagnosis of the intercondylar distal humerus fracture. Intraoperatively, the patient had the radial nerve entrapped between the proximal metaphyseal fragment and distal lateral condyle of the humerus. CONCLUSION: Preoperative radial nerve palsy associated with the intercondylar distal humerus fracture is very rare. Fractures with the significant anterolateral displacement of the proximal metaphyseal fracture segment may entrap the course of the radial nerve in the anterior compartment of the distal humerus and thus manifest as radial nerve palsy.

What Is the Normal Trajectory of Interleukin-6 and C-reactive Protein in the Hours and Days Immediately After TKA?

BACKGROUND: Some patients with early periprosthetic joint infection (PJI) can be treated successfully using open débridement with polyethylene exchange rather than two-stage revision; however, the challenge is to diagnose PJI early. In late infection, C-reactive protein (CRP) and interleukin-6 (IL-6) are elevated, but shortly after surgery, CRP is difficult to interpret because it may be elevated even in the absence of infection, and we know little about the normal trajectory of IL-6 immediately after arthroplasty. If a deviation of biomarkers from their normal trajectory is seen, it may help guide the clinician toward early knee aspiration. QUESTIONS/PURPOSES: We studied the normal trajectories of IL-6 and CRP in the immediate hours and days after uncomplicated TKA and examined whether one or the other normalizes more quickly. METHODS: We studied serum IL-6 and CRP levels in 50 patients undergoing primary TKA at five time points: 12 hours preoperatively and postoperatively at 12 hours, 48 hours, 4 days, and 2 weeks. One surgeon operated on all patients using the same approach and postoperative management. The same laboratory methods were used each time. Results are presented as median and range. Repeated-measures analysis was done using Friedman's (nonparametric) test. No patient showed any clinical sign of infection during our study period. All patients were followed up until 1 year with no evidence of infection and good knee scores. RESULTS: IL-6 showed a sharp rise from its baseline with a preoperative median value of 6 pg/mL (range, 3-17 pg/mL) to a peak of median value of 133 pg/mL (range, 15-359 pg/mL) at 12 hours postoperatively. At 48 hours, IL-6 had declined to a median value of 82 pg/mL (range, 12-309 pg/mL). At 4 days, it had further declined to a median value of 22 pg/mL (range, 5-67 pg/mL). At 2 weeks, IL-6 reached a median value of 7 pg/mL (range, 3-14 pg/mL), which was not different from the baseline median value with the numbers available (p = 0.455). CRP showed a gradual rise from its baseline preoperative median value of 2 mg/L (range, 1-17 mg/L) to a median value of 15 mg/L (range, 2-111 mg/L) at 12 hours postoperatively, which peaked at 48 hours to a median value of 125 mg/L (range, 22-247 mg/L). At 4 days postoperatively, CRP levels had declined to a median value of 69 mg/L (range, 21-234 mg/L). At 2 weeks, CRP had reached a median value of 12 mg/L (range, 1-72 mg/L), which was still higher than the baseline median value with available numbers (p < 0.001). CONCLUSIONS: We found that after uncomplicated TKA, IL-6 showed a sharp rise to peak at 12 hours, then fell rapidly to near baseline levels by 4 days and returned to the baseline level at 2 weeks. CRP showed a gradual rise to peak at 48 hours, then fell gradually, remaining elevated at 4 days and higher than baseline level at 2 weeks. Future studies can help define more definitive thresholds for IL-6 and CRP; ideally, these should derive from large, multicenter studies. With such data, any deviation from a known normal trajectory can facilitate a quicker decision to perform knee aspiration to diagnose early PJI more promptly. LEVEL OF EVIDENCE: Level III, diagnostic study.

Effect of Intravenous Zoledronic Acid on Histopathology and Recurrence after Extended Curettage in Giant Cell Tumors of Bone: A Comparative Prospective Study.

BACKGROUND: Giant cell tumor (GCT) of the bone is known for its locally aggressive behavior and tendency to recur. It is an admixture of rounded or spindle-shaped mononuclear neoplastic stromal cells and multinucleated osteoclast-like giant cells with their proportionate dispersion among the former. Zoledronic acid (a bisphosphonate) is being used in various cancers such as myelomas and metastasis, for osteoporosis with an aim to reduce the resorption of bone, and as an adjuvant treatment for the management of GCT of bone for reduction of local recurrence. We have carried out a prospective comparative study to assess the effect of intravenous infusion of zoledronic acid on histopathology and recurrence of GCT of bone. MATERIALS AND METHODS: The study was carried out in the biopsy proven GCTs in 37 patients; 15 males and 22 females, in the age range from 17 to 55 years. They were treated with extended curettage. Of these 37 patients, 18 were given three doses of 4 mg zoledronic acid infusion at 3-week intervals and extended curettage was performed 2 weeks after the last infusion whereas the other 19 were treated with extended curettage without zoledronic infusion. The post infusion histopathology of the curetted material was compared with the histopathology of initial biopsy. All the patients were evaluated at 3-month intervals for the first 2 years and then six monthly thereafter, for local recurrence and functional outcome of limb using the Musculoskeletal Tumor Society (MSTS) score. RESULTS: In postzoledronic infusion cases, the histopathology of samples showed abnormal stromal cells secreting matrix leading to fibrosis and calcification. The type of fibrosis and calcification was different from pathological calcification and fibrosis what is usually observed. There was a good marginalization and solidification of tumors which made surgical curettage easier in six cases in the study group. There was noticeable reduction in the number of giant cells and alteration in morphology of stromal cells to the fibroblastic-fibrocytic series type in comparison to preinfusion histopathology. Recurrence occurred in one case out of 18 patients in infusion group whereas in four cases among 19 patients in control group. The functional results were assessed, and the overall average MSTS score was 27.50 (range 24-30) and 27.00 (range 23.50-30) in the study and control groups, respectively. CONCLUSIONS: We observed that bisphosphonates reduce osteoclast activity and affects stromal cells in GCT, resulting in the reduction of their numbers and noticeable apoptosis. This results in better marginalization of the lesions and reduced recurrence. Extended curettage of friable GCT became easier and adequate which otherwise might not have been possible.

Spectrum of Congenital Anomalies among Surgical Patients at a Tertiary Care Centre over 4 Years.

Introduction. Congenital anomalies are important causes of childhood death, chronic illness, and disability in many countries. Congenital malformations are rapidly emerging as one of the major worldwide problems. Aim. To study the percentage of various congenital anomalies among the patients admitted in Department of Pediatric Surgery at a tertiary care centre over a period of four years from 2011 to 2015 in our centre. Results. Neural tube defects were found to be the most common anomalies in 24.3% of the children admitted. Other common anomalies were anorectal malformation (20.7%), tracheoesophageal fistula (20%), and intestinal obstruction (14.84%). Majority (60.5%) of the patients were males. Conclusion. Congenital malformations are rapidly emerging as one of the major worldwide problems as they can result in long-term disability, which may have significant impacts on individuals, families, health-care systems, and societies. Regular antenatal visits and prenatal diagnosis are recommended for prevention, early intervention, and even planned termination, when needed.

Congenital Lumbar Hernia: A 15-Year Experience at a Single Tertiary Centre.

Aim. Congenital lumbar hernia is an uncommon anomaly with only few cases reported in the English literature. This study was done to study the incidence, age at presentation, sex, associated anomalies, surgical management, and postoperative morbidity and mortality of congenital lumbar hernia in pediatric patients. Methods. Retrospective analysis of all patients of CLH over a period of 15 years (January 2000 to December 2015) was analyzed. Results. A total of 14 patients were encountered in this series. All presented within first 2 years of age. 12 were males and 2 were females. All of them presented with swelling in lumbar region. 13 were unilateral and 1 was bilateral. Left sided hernia was observed in 2 cases only. Lumbocostovertebral syndrome was found in all the patients in addition to other rare anomalies. All cases were managed with open surgical repair. Wound infection was seen in 2 cases. There was no mortality in our series. Conclusion. CLH is very rare among hernias. Surgery should be carried out within 1 year of age. For a defect of <5 cm, primary repair is done. For a defect of >5 cm, meshplasty should be considered. Prognosis is excellent.