Metaphyseal sleeves in revision total knee arthroplasty: Minimum seven-year follow-up study.

BACKGROUND: Metal metaphyseal sleeves are an option for reconstruction as well as enhancing fixation in managing challenging bone defects in revision knee replacement. We report our results of revision knee replacement using metaphyseal sleeves with a minimum of seven years of follow-up. METHODS: The records of 103 patients (104 knees) who underwent revision knee replacement using metaphyseal sleeves in our centre were evaluated. The follow-up included clinical assessment, functional scores and radiologic assessment. RESULTS: The mean age of patients was 74.7 (tange 58-92) years. Mean follow-up was 95.7 (range, 88-115) months. From the original cohort, 15 (14%) patients had died from unrelated causes. During the follow-up period, there were 23 (22.1%) re-revisions. Indications for re-revision was aseptic loosening in seven (6.7%), stiffness in four (3.8%), infection in five (4.8%), instability in three (2.8%) and persistent pain in two (1.9%) patients. For aseptic loosening, the average time for re-revisions was 56.6 months (range 25 to 84). Radiographically, all unrevised sleeves were well-fixed, without any evidence of loosening. Oxford knee score in patients without re-revisions was 28.5 (range four to 48). CONCLUSION: At mid-term follow-up, metaphyseal sleeves demonstrate durable clinical results and radiographic fixation.

Comparative study of single lateral locked plating versus double plating in type C bicondylar tibial plateau fractures.

BACKGROUND: Bicondylar tibial plateau fractures are complex injuries and treatment is challenging. Ideal method is still controversial with risk of unsatisfactory results if not treated properly. Many different techniques of internal and external fixation are used. This study compares the clinical results in single locked plating versus dual plating (DP) using two incision approaches. Our hypothesis was that DP leads to less collapse and change in alignment at final followup compared with single plating. MATERIALS AND METHODS: 61 cases of Type C tibial plateau fractures operated between January 2007 and June 2011 were included in this prospective study. All cases were operated either by single lateral locked plate by anterolateral approach or double plating through double incision. All cases were followed for a minimum of 24 months radiologically and clinically. The statistical analysis was performed using software SPSS 10.0 to analyze the data. RESULTS: Twenty nine patients in a single lateral locked plate and 32 patients in a double plating group were followed for minimum 2 years. All fractures healed, however there was a significant incidence of malalignment in the single lateral plating group. Though there was a significant increase in soft tissue issues with the double plating group; however, there was only 3.12% incidence of deep infection. There was no significant difference in Hospital for special surgery score at 2 years followup. CONCLUSION: Double plating through two incisions resulted in a better limb alignment and joint reduction with an acceptable soft tissue complication rate.

Impact of patellar height on unicompartment knee arthroplasty: does patella baja lead to an inferior outcome?

BACKGROUND: Though a number of series with long-term results have been published, there is still a paucity of literature on the role of patellar height after unicompartment knee arthroplasty (UKA). The present study was conducted with a hypothesis that patella baja may lead to a poor outcome at follow-up. MATERIALS AND METHODS: A retrospective review of 134 knees was performed and patellar height calculated before and after UKA by Blackburne-Peel index (BPI) and the Insall-Salvati ratio (ISR) on true lateral radiographs of the patients in 30° of flexion taken pre-operatively and at 1 year, 2 years and final follow-up (minimum 5 years). Statistical analysis was performed to evaluate the outcomes. RESULTS: There was a decrease in ISR in 14.18 % and in BPI in 19.4 % at final follow-up. There was a significant decrease in BPI values while the decrease was not significant for ISR. After eliminating the pre-operative patella baja, 7.3 % developed post-operative patella baja, according to ISR, while 11.5 % developed patella baja as per BPI. At final follow-up there was a statistically significant decrease in stair climbing scores in patients with patella baja when compared to patients with normal ISR. CONCLUSION: Patients with a decrease in patellar height as per ISR have a decrease in stair climbing score at mid-term follow-up while the overall KSS, and pain scores are not affected by a change in patellar height and neither is there a significant progress in patellofemoral osteoarthritis among patients with patella baja compared to normal patella.

Role of nonoperative treatment in managing degenerative tears of the medial meniscus posterior root.

BACKGROUND: Tears of the medial meniscus posterior root can lead to progressive arthritis, and its management has no consensus. The aim of our study was to evaluate the effect of supervised exercise therapy on patients with medial meniscus posterior root tears. MATERIALS AND METHODS: Between January 2005 and May 2007, 37 patients with this tear verified by magnetic resonance imaging (MRI) and osteoarthritis grade 1-2 by radiographic examination were treated by a short course of analgesics daily for up to 6 weeks and then as required during follow-up, as well as a 12-week supervised exercise program followed by a home exercise program. Final analysis was performed for 33 patients, average age 55.8 (range 50-62) years and average follow-up of 35 (range 26-49) months. Patients were followed up at 3, 6, and 12 months and yearly thereafter using the Lysholm Knee Scoring Scale, Tegner Activity Scale (TAS), and visual analog scale (VAS). The analysis was performed using one-way analysis of variance (ANOVA) and Pearson's correlation coefficient to determine the relationship between Lysholm score and body mass index (BMI). RESULTS: Patients showed an improvement in Lysholm score, TAS, and VAS, which reached maximum in 6 months and later was accompanied by a decline. However, scores at the final follow-up were significantly better than the pretherapy scores. There was also a progression in arthritis as per Kellgren and Lawrence radiographic classification from median 1 preintervention to median 2 at the final follow-up. A correlation between BMI and Lysholm scores was seen (r = 0.47). CONCLUSION: Supervised physical therapy with a short course of analgesics followed by a home-based program results in symptomatic and functional improvement over a short-term follow-up; however, osteoarthritis progression continues and is related to BMI.

Irreducible dislocation of all the lesser metatarsophalangeal joints of the foot: a case report.

We report a case of irreducible dorsal dislocation of all the lesser metatarsophalangeal joints of the foot following injury at sport. Plantar plate prevented reduction at all the joints, which necessitated an open reduction and stabilization with K-wire. This report highlights the necessity of prompt open reduction and reviews the mechanism of injury and complex anatomy at metatarsophalangeal joint.

Tubercular osteomyelitis of distal ulna presenting as epiphyseal injury.

Tuberculosis (TB) continues to be a public health problem in both developing and industrialized countries. T.B can involve any bone theoretically but involvement of distal metaphysis and epiphysis is a rare presentation. We present a case of 11yr old female child who presented to us with pain and swelling in distal forearm and radiograph revealing an osteolytic lesion in distal ulnar metaphysic and volar displacement of epiphysis. Histopathology and BACTEC culture led us to a diagnosis. Awareness of atypical presentations of TB is most important in endemic areas to ensure proper management of such patients.

IIlizarov external fixator for bilateral severe flexion deformity of the knee in haemophilia: case report.

INTRODUCTION: Deformity correction by Illizarov method in haemophilic patients is a rare phenomenon. AIM: To correct the bilateral knee deformity by Illizarov in one sitting. MATERIALS AND METHODS: Patient had fixed flexion deformity (100 degrees ) of both knees; posterior skin webs, posterior subluxation, wasting of quadriceps and <1% level of factor IX. Patient was managed with optimisation of factor IX level in perioperative period by factor IX supplementations. Deformities were corrected by Illizarov's fixator on both lower limbs at 3 months and fixator was removed at 4 months. At 3 months, patient developed bilateral equinus deformity which was corrected by a dynamic foot sling and gentle tendoachillis stretching exercises. RESULT: Patient had superficial pin tract infection at three sites. There were no episodes of bleeding from pin tracts or in knee joint during distraction period. Patient had bilateral knees flexion up to 120 degrees with 5 degrees extensor lag on the right side. Patient is going to college and walks with intermittent use of a hinge knee brace at 3 years follow-up. CONCLUSION: Illizarov method is a safe, less invasive, effective, economical and truly biological method for correction of severe flexion deformities of knee in haemophilic patients.

Total hip arthroplasty in patients with active tuberculosis of the hip with advanced arthritis.

UNLABELLED: Osteoarticular tuberculosis (TB) in the hip and other joints is increasing and patients in developing countries commonly present with advanced joint destruction. We asked whether TB is reactivated after THA in these patients. We retrospectively reviewed 12 patients with an average age of 45 years who had advanced stages of hip destruction secondary to mycobacterium TB and who were treated with primary THA and prescribed perioperative antituberculous medication for 12 to 18 months postoperatively. Diagnosis in all these patients was confirmed by histopathology and culture. The minimum followup was 25 months (average, 41 months; range, 25-58 months). We observed no reactivation of TB in 11 patients who had Harris hip scores ranging from 86 to 97. One patient who postoperatively did not comply with the antituberculous chemotherapy had reactivation and superimposed infection through a nonhealing sinus tract; that patient underwent component removal and resection arthroplasty. When the infected tissue can be débrided and adequate antituberculous therapy is instituted the outcome of joint arthroplasty may not be adversely affected. THA in the tuberculous hip has a low risk of reactivation and produces good functional results. LEVEL OF EVIDENCE: Level IV, therapeutic case series (no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.

Rotational alignment of femoral component and flexion gap balance in patients with distal femoral torsional deformity using navigation-assisted TKA.

We evaluated the rotational alignment of the femoral component after total knee arthroplasty in 46 patients with distal femoral torsional deformity using a navigation-assisted gap technique. Preoperative distal femoral torsional angle and postoperative rotational deviation of the femoral component were measured using computed tomography. Flexion gap data were obtained from intraoperative navigation measurements. The mean rotational deviation of the femoral component was 4.1 degrees (range, 2 degrees -6 degrees ) internal rotation in reference to transepicondylar axis (TEA). The femoral component was not aligned within 3 degrees in reference to TEA in 30 patients (65.2%). There was no significant difference of rotational deviation of the femoral component between unbalanced and balanced flexion gap groups (P=.65). There was a significant improvement of clinical outcomes after TKA. Navigation-assisted gap technique provided balanced flexion gaps in most patients, although there were wide rotational deviations of femoral components. Using the anatomic bony landmark method can result in excessive external rotation of the femoral component and unbalanced flexion gaps in patients with distal femoral torsional deformity.

Delayed periprosthetic tuberculosis after total knee replacement: is conservative treatment possible?

Tuberculosis of a prosthetic knee joint is rare. Early diagnosis would improve the outcome, but this is usually not achieved. We report the case of a 73-year-old woman who presented with a painful and swollen knee joint, 14 years after total knee arthroplasty. Radiographs and haematological investigations were inconclusive. Synovial tissue and pus obtained by needle biopsy did not reveal any microorganism on smear examination nor in culture. A diagnosis of tuberculosis was made on the basis of a positive polymerase chain reaction. The patient made a complete recovery following brace immobilization for 3 weeks and administration of anti-tubercular drugs for 18 months. There was no recurrence after a follow-up period of 3 years. Awareness of delayed tuberculosis as an important differential diagnosis in infected prosthetic joints helps to avoid delay in management. The authors found 23 other cases of periprosthetic tuberculosis after total knee or hip replacement. Their case is probably the only periprosthetic knee tuberculosis in the literature which healed with medication only. This shows that conservative treatment is possible when there is no loosening of the implant. However, surgical treatment is necessary in most cases and must be individualized.

Tubercular infection after arthroscopic anterior cruciate ligament reconstruction.

PURPOSE: Tubercular infection has not been described, to our knowledge, in the literature after anterior cruciate ligament (ACL) reconstruction, and, hence, the purpose of our case series was to describe our experience, evaluate the clinical and laboratory findings, and assess the treatment outcome. METHODS: We performed a retrospective analysis of 1,152 cases of arthroscopic ACL reconstruction with autografts performed at our institution between January 1998 and May 2007. Tubercular infection was considered to be present in the setting of recurrent negative bacterial cultures but a positive result on microscopy, culture, histopathology, or polymerase chain reaction (PCR). All patients underwent arthroscopic lavage and synovectomy, followed by antitubercular therapy for 12 months. RESULTS: We identified 8 patients (0.69%) with infection. Bone-patellar tendon-bone graft was used in 1 and hamstring graft in 7. All patients were immunocompetent. The mean time from surgery to presentation was 64.4 days (range, 23 to 152 days). Aspirate fluid staining and culture for acid-fast bacilli was negative in all cases, synovial tissue culture was positive in 3, characteristic histopathology was positive in 7, and PCR was positive in 6. A mean of 1.25 surgeries (range, 1 to 2) were performed. The mean length of follow-up in our series was 43.6 months (range, 25 to 73 months), with no reinfections. The mean postoperative Lysholm knee score was 80. CONCLUSIONS: Tubercular infection as a complication after arthroscopic ACL reconstruction, though rare, should be kept in mind as a possible cause of infection in immunocompetent patients in zones endemic for tuberculosis. It should also be kept in mind in nonendemic areas, among immigrants from endemic areas, and in cases with persistent swelling and discharge, effusion with minimal inflammatory signs, and negative cultures. We recommend deoxyribonucleic acid-PCR testing for early diagnosis of tuberculosis. Arthroscopic debridement and antitubercular chemotherapy together are the mainstay of treatment.

Femoral allograft in the management of osseous hydatidosis presenting as femoral shaft non-union.

Osseous hydatidosis is a rare infection posing diagnostic and therapeutic challenge. We present a case of extensive hydatidosis of the femoral shaft with non-union of pathologic fracture. Patient had resection of involved femur and post-operative chemotherapy. Subsequently femur reconstruction was done using a femoral allograft. At 26 months patient has no recurrence and bony union is seen at host-allograft interface. We present this technique as an extended indication of allograft used in limb reconstruction.