Evaluation of Flexor hallucis tendon transfer in chronic insertional Achilles tendinopathy in over 50-year-old population using validated ankle scores.

PURPOSE: Chronic insertional Achilles tendinopathy is a common pathology in the over 50 years old population. Patients not relieved with conservative treatment had to undergo surgical intervention for the management. This study evaluates the clinical outcome of FHL transfer in such patients using validated ankle functional scores. METHOD: It is a retrospective study including 20 patients of either gender managed with debridement of the distal degenerative remnant Achilles tendon fibers either at the insertion site or the distal end of the torn tendon, resection of Haglund deformity with FHL transfer, and reattachment of Achilles tendon. The average age of the patients was 56.55 + 11 years (50-77 years) followed by over 35.6 months (Range 22-48months). The preoperative FAAM, FADI, SF 36, VAS, and AOFAS scores were calculated and followed every 6 months. The plantarflexion and dorsiflexion of the ankle were also recorded preoperatively and at follow-up visits. RESULTS: All the patients were operated on by a single surgeon (MS) with the same surgical technique, implant, and rehabilitation protocol. All the patients were followed for an average of 35.6 months (Range 22-48 months). All the ankle scores, FAAM, FADI, SF36, VAS, and AOFAS improved in follow-ups. The mean plantarflexion and dorsiflexion were 39.300+ 4.90 and 12.50+ 4.70 respectively. Three patients had minor wound complications. All the patients returned to activities of daily living. CONCLUSION: FHL transfer in elderly patients with insertional Achilles tendinopathy improves the validated ankle functional scores and decreases pain significantly. Furthermore, randomized studies with a larger study population and longer follow-ups may ascertain the beneficial effects.

A comprehensive 3D CT based classification of intertrochanteric fracture.

Introduction: Despite advancements in surgical techniques complications like implant failure is very common after the fixation of intertrochanteric fractures. Classifying these complex fractures based on plain radiographs underestimates the complexity of these fractures which in turn leads to complications. We propose a comprehensive classification of the intertrochanteric fractures based on 3D Non Contrast Computed Tomography (3D NCCT) scan. Material and methods: A total of 102 patients (51 males and 51 females) with intertrochanteric fractures were included in this study conducted over a time period of 22 months in a Tertiary care center in North India. NCCT proximal femur of the intertrochanteric fracture patients was done to formulate a new CT classification system and classify all fractures. Intra and inter-observer reliability was tested using kappa variance. Results: New classification system was proposed which included 3 main and a total of 6 groups. All the fractures were classifiable into the new system. Kappa variance of the study showed a good intra and interobserver reliability (0.95 and 0.90) proving clinical agreement of the classification. Conclusion: This new 3D-CT based classification has the advantages of being easy, comprehensible with high intra and inter-observer reliability. This 3DCT based classification can prove to be useful to detect occult intertrochanteric fractures undetectable in plain radiographs as well as choosing the optimum treatment plan.

Comparison of functional outcomes and complications of cemented vs uncemented total hip arthroplasty in the elderly neck of femur fracture patients: A systematic review and meta-analysis.

Purpose: The neck of femur fractures in the elderly is a global concern. These fractures impair the quality of living and add to morbidity and mortality. A Multitude of treatment options for the same. This systematic review focuses on evaluating outcomes between cemented and uncemented total hip replacement in the elderly population with neck of femur fractures. Material and methods: The search was conducted in databases PubMed, Embase, Scopus, open grey, and Cochrane following PRISMA guidelines. The studies fulfilling the inclusion criteria were included, scrutinized for data analysis, and also quality appraisal of all the included studies was conducted to be included in this article. Results: A total of 7 studies were included (2 RCT, 5 retrospective studies) comprising 1171 THRs. Data analysis showed a higher HHS in cemented compared to uncemented(p < 0.001). The uncemented group had a significantly higher rate of revision, dislocation, and periprosthetic fracture compared to cemented group(p < 0.001). However, VAS score, loosening rates, and heterotopic ossification were similar in both statistically insignificant groups. Conclusion: Choosing between cemented and uncemented techniques had been a controversy with lesser data due to higher morbidity and mortality. This systematic review provides information regarding functional outcomes and complications in both groups. The cemented group had better outcomes and lesser complications which should be preferred in elderly patients as the conclusion of this study. However, a larger RCT with better follow-up is still required. Level of evidence: Level I, systematic review and meta-analysis.

Outcome of Atypical & Complex Clubfoot Managed by Modified Ponseti Method-A Prospective Study.

Atypical or complex clubfoot constitutes a small number of cases. Due to the difference in complexity of anatomy, standard deformity correction by Ponseti is not effective. Hence a modified Ponseti method was advised which focuses on deformity differences for treatment. We conducted a prospective study to analyze the outcome in atypical or complex clubfoot treated with the modified Ponseti method. All the children of age less than 1 year were included in the study with atypical or complex clubfoot. Every case was treated according to the modified Ponseti method and tenotomy. Pirani scores were measured at pretreatment, each visit, before application of a brace, and at the latest follow-up. Statistical analysis of all continuous and categorical variables was done. A total of 30 patients (47 feet) were included in the study. Mean Pirani score improved from 5.69 at presentation to 0.45 at time of brace application and latest follow-up 0.34 (p < .001). Six patients (9 feet) had a relapse which was managed with recasting. The mean Pirani score of relapse was 0.72, which after correction reduced to 0.11 (p = .008). Six patients had cast-related complications which were managed with conservative treatment. With an increase in popularity of the Ponseti method, a greater number of complex clubfoot cases are seen due to inadequate reduction or slippage of cast or improper cast application techniques. All these need to be identified at an early age. This helps in proper treatment and improves the quality of life as well as foot appearance.

Infection and utilization rates of bone allografts in a hospital-based musculoskeletal tissue bank in north India.

BACKGROUND: The bone bank unit of interest in this article was established in January 2018, in a tertiary care teaching institute of north India. Aim of this article is to describe the sources of allografts obtained, discard rates of allografts and infection rates in the recipients after use. MATERIAL AND METHODS: All the relevant details of donors and recipients were maintained, and donors were screened for standard inclusion and exclusion criteria before obtaining the grafts. Aerobic culture was performed before storage and just prior to use. Samples with incomplete documentation, incomplete donor screening or positive cultures were discarded. Data on surgical site infection in recipients was collected from hospital records retrospectively. Initially ELISA based serological tests were used for screening. Donor has to undergo these tests again after 6 months to account for the window period of proliferation of viruses. Nucleic acid amplification tests (NAAT) for these viral agents were introduced in the hospital in May 2018. RESULTS: Allografts from a total of 196 donors were obtained in the bone bank over 2 years. Major source of bone was femoral heads harvested during total hip arthroplasty or hemi-arthroplasty. 44(22.4%) grafts had to be discarded. 95 allografts were used in 88 patients during this time. Most common indication for use was surgery for bone tumors (40%), followed by complex primary or revision arthroplasty (30.5%). Three (3.4%) recipients developed deep infection postoperatively. CONCLUSION: Frozen allograft bone from hospital based bone banks is a reliable source of allografts. When meticulous precautions for sterility are followed, risk of infection is low. Monitoring of such bone banks should fall within a framework of the local legislature. Incomplete documentation is the major reason for wastage of the samples obtained. NAAT may be useful in screening of donors, as it reduces the wastage and the holding time of the allografts.

Bilateral Proximal Humerus Fracture with Anterior Shoulder Dislocation and Unilateral Chronic Bankart Lesion - A Case Report.

INTRODUCTION: Anterior shoulder dislocation is a common presentation in orthopedic emergency but a bilateral fracture dislocation is a rare entity. Only a few cases have been reported in the literature and their management is still not clear. We present a bilateral four part fracture dislocation with Bankart lesion on right side in a 48 years old. CASE REPORT: A 48-year-old male presented with bilateral proximal humerus fracture with anterior shoulder dislocation following a seizure. He was managed with bilateral PHILOS and Latarjet procedure on right side for a chronic bony Bankart lesion. Superficial infection on left side was managed with debridement. After 1 year period patient had a satisfactory outcome with DASH score of 19.2. CONCLUSION: Bilateral four part proximal humerus fracture with shoulder dislocation is encountered rarely. Recurrent dislocations results in chronic glenoid bones loss which needs fixation along with fracture. Addressing both sides subsequently or in a single sitting is still debatable.

CT Based Analysis of Acetabular Morphology in Northern Indian Population: A Retrospective Study.

PURPOSE: The acetabular morphology has shown to differ among different regions of the world. Multiplanar evaluation by computed tomography (CT) scan is the key to assess acetabular depth, version, and inclination at the same time which have been rarely explored before in the Indian population. We present an anthropometric study of the native acetabulum by CT based coronal, sagittal, and axial parameters in the Northern Indian population. METHODS: The acetabular anteversion (AA), acetabular angle of sharp (AAS), sagittal acetabular angle (SAA), lateral center edge angle (LCEA), acetabular depth (AD), acetabular horizontal offset (AHO), extrusion index (EI) and acetabular depth ratio (ADR) was measured in CT scans of 122 patients (244 hips) without any bony pathologies. LCEA < 20°, ADR < 250, AD < 9 mm, AAS > 43°, and EI ≥ 25% were taken as criteria for dysplastic acetabulum. RESULTS: There were 62 males and 60 females included in the study with a mean age of 63.8 ± 17.2 years (21-98 years). In this study, females were having significantly lower ADR (p = 0.002) and higher EI (p = 0.01) than males. The prevalence of dysplasia was 3.2% according to LCEA and 1.6% while combining all of the criteria. CONCLUSION: There are prominent differences in acetabular depth in the Indian population compared with the population of Western countries or other parts of Asia. Females were shown to have shallower acetabulum than males. The comparative analysis of radiographic parameters obtained from our study with the data available on different country-based studies can help better understanding the acetabular morphology of Indian as well as the worldwide population. LEVEL OF STUDY: Retrospective cross-sectional study.

Assessment of thickness of in vivo autograft tendons around the knee and its correlation with anthropometric data, thickness of patella and anterior cruciate ligament tibial foot print diameter.

Inadequate diameters of the autograft tendons are known to be a major cause of graft failure in ligament reconstruction. The purpose of the study was to measure the in-vivo thickness of the available autograft options around the knee and to seek a correlation between the thickness of the tendons and the anthropometric data, patellar thickness and anterior cruciate ligament (ACL) footprint sagittal diameter. Magnetic resonance imaging of 104 consecutive patients with suspected knee injuries were utilized for measurement of the in vivo thickness of pes anserinus tendon (diameter and cross-sectional area [CSA]), patellar tendon (PT) and quadriceps tendon (QT). Pearson's coefficient was used to find out the relationship between the tendon thickness and anthropometric data, thickness of patella and ACL tibial foot print sagittal diameter. The mean diameters and CSA of the semitendinosus tendon (ST) and gracilis tendon (GT) were 3.77±0.49 mm, 11.62±1.62 mm2 and 2.87±0.27 mm, 6.64±1.18 mm2 respectively. QT and PT thicknesses were 7.36±0.87 mm and 4.50±0.62 mm respectively. Height and the patellar thickness were seen to have moderate correlation with ST and PT thickness. Weak correlation was seen between the other anthropometric variables and tendon thickness. Magnetic resonance imaging (MRI) assessment of tendon sizes is a reliable method with good inter and intra-rater agreement. Assessment of these anatomical structures with help of MRI would be helpful in preoperative planning and can help in identifying those patients at risk of having smaller tendons.

Ollier's Disease - Rare Presentation of the Rare Disease.

Introduction: Enchondromas are benign lesion of cartilaginous origin seen in early childhood. Multiple enchondromatosis is also known as Ollier's disease which involves the appendicular skeleton with multiple site involvement. We present a rare case of appendicular as well as axial skeleton involvement in a case of Ollier's disease. Case Report: A 13-year-old male with multiple enchondromas including all the appendicular skeleton along with ribs and cervical spine. Patient was evaluated with X-rays and non-contrast computerized tomography and is on conservative treatment and on regular monthly follow-up with no neurological deficit and no respiratory complications till now. Further evaluation for deformity correction if required, will be considered after skeletal maturity. Conclusion: Ollier's disease is a rare presentation with multiple enchondromas in the appendicular skeleton. Current case is further rare presentation of the Ollier's disease with involvement of cervical spine and ribs as well.

Assessment of Anterior Cruciate Ligament Tibial Footprint Sagittal Diameter and Orientation of the Ligament in the Intercondylar Notch in Indian Population: A Magnetic Resonance Imaging (MRI) Analysis.

AIM: To study the relevant anatomy of anterior cruciate ligament tibial footprint and orientation of the ligament in the intercondylar roof in Indian population the using MRI. METHODS: A total of 70 knee MRI with intact anterior cruciate ligament (ACL) was assessed for intercondylar roof angle, ACL inclination angle, ACL-bluemensaat angle, ACL sagittal center, and tibial insertion size. RESULTS: The ACL tibial sagittal center was found to be at 43.5% of the anteroposterior tibial length. Tibial insertion size averaged 15.40 (±1.29) mm with no significant difference in males and females (p > 0.05). The roof angle was 36.29 (± 4.02) ˚ and the ACL inclination angle and ACL-bluemensaat angle were 51.22 (± 3.39) ˚ and 4.70 (±3.35) ˚ respectively with no significant sex difference (p > 0.05). CONCLUSION: The ACL tibial insertion size averaged 15.40 mm and its center was at 43.51% along the Staubli and Rauschning line. The mean roof angle was 36.29 degrees and the ACL-bluemensaat angle was 4.70 degrees. Understanding of the tibial footprint morphology and the relation of the ligament to the roof of the intercondylar notch helps in anatomical graft placement during reconstruction.