Arthroscopic lasso-loop technique for subscapularis repair with anterolateral viewing portal yields better clinical outcomes for Lafosse grade 3 and 4 tears: a prospective study with minimum 2 years of follow-up.

Background: Contracted subscapularis tears, especially Lafosse grade 3 and 4, pose a significant challenge in surgical repair due to the need for extensive release of retracted tendon and the risk of cut-through due to poor tissue quality. The posterior viewing portal may hinder adequate visualization and extensive release of retracted tendons, particularly in addressing the bursal surface of the tears. Tension-free robust repair is critical to prevent retears and for achieving successful outcomes for these massive and complex retracted tears. This study investigates the clinical outcomes of the Lasso-Loop technique with an anterolateral viewing portal, aiming to enhance tendon release, improve footprint fixation, and optimize tissue grip, particularly in cases of chronic retracted Lafosse 3 and 4 tears. This innovation also eliminates the need for arthroscope switching and serves as a crucial measure for averting axillary nerve injuries during the procedure. Methods: The study included 40 patients with isolated subscapularis or combined anterosuperior rotator cuff tears (Lafosse grade 3 and 4) that underwent arthroscopic subscapularis repair using a Lasso-Loop technique through an anterolateral viewing portal. Evaluations were conducted both preoperatively and at predefined postoperative intervals: 6 weeks, 3 months, 6 months, 1 year, and 2 years. The evaluations in this study encompassed a comprehensive range of clinical assessments, which included a complete range of movements, specialized tests for subscapularis muscle functionality (specifically the lift-off test and belly press test), the utilization of the University of California at Los Angeles and Oxford shoulder scoring systems, and a postoperative ultrasonography conducted at the 6-month mark to assess the presence of any retear. Clinical outcomes were compared with that of the opposite normal shoulder. Results: There was considerable improvement in the active painless range of motion postoperatively. During the 2-year follow-up, the positive belly press test decreased from 50% (n = 20) to 2.5% (n = 1), while the positive lift-off test decreased from 100% (n = 40) to 5% (n = 2). The modified University of California at Los Angeles score increased significantly from 10.15 preoperatively to 30.17 at 2 years postoperatively (P value = .001). Oxford's Shoulder Score increased significantly from 15.6 preoperatively to 40.64 at 2 years postoperatively (P value = .001). Conclusion: This technique has produced positive functional outcomes, in cases categorized as massive subscapularis tears and chronic tears indicating the superiority over other conventional techniques of subscapularis repair described in the literature.

Challenges and Solutions: Total Knee Replacement in Patients with Chronic Lymphatic Filariasis: A Case Report.

CASE: A 59-year-old woman with a history of left knee pain exacerbated by lymphatic filariasis underwent successful total knee replacement (TKR) for advanced osteoarthritis. Postoperatively, diligent adherence to compression bandaging, physiotherapy, and lymphatic flow promotion resulted in no lymphedema progression. During the 5-year follow-up, the patient showed improved Knee injury and Osteoarthritis Outcome Score and stable implant. CONCLUSIONS: Currently, there are no established protocols or formulated guidelines for TKR in patients with chronic filariasis. The preoperative lymphedema prevention must be tailor-made for each patient in the context of advanced osteoarthritis based on the functional lymphatic vessel status.

Diagnosis and treatment approach of delayed presentation of anterior branch axillary nerve injury following shoulder dislocation: case report.

In this case report, a unique instance of delayed isolated anterior branch axillary nerve injury following shoulder dislocation is highlighted. The patient, a 55-year-old manual laborer, presented with severe deltoid wasting and reduced power 18 months postdislocation, necessitating a specialized treatment approach. The use of axillary nerve neurolysis and an innovative upper trapezius to anterior deltoid transfer via a subacromial path posterior to the clavicle, facilitated by an autologous semitendinosus graft, resulted in significant improvement with 160 degrees of abduction and Grade 4+ power Medical Research Council grading (MRC) at the 5-year follow-up.

Arthroscopic double row partial articular supraspinatus tendon avulsion bridge repair technique for shoulder: A transtendinous approach.

Partial articular supraspinatus tendon avulsion (PASTA) lesions, a subset of partial rotator cuff tears, pose a surgical challenge, disrupting the integrity of the supraspinatus tendon. Transtendinous repair is the preferred choice in young individuals for limiting tear progression and preserving intact, high-quality cuff tissue, thus preventing tendon shortening, as compared to the tear completion and repair technique. Our approach leverages these advantages, specifically those indicated for Ellman's Grade 3 tears and cases where conservative treatments have failed. In our technique, we employ progressive dilation, anchor drill sleeve insertion to facilitate medial row anchor placement, followed by percutaneous spinal needles for suture shuttling, and finally locking sliding knots for compressive medial row repair, followed by lateral row fixation for additional stability. This method accelerates rehabilitation and restores optimal shoulder function.

All-arthroscopic versus mini-open double row rotator cuff repair - A prospective randomised control study based on functional and radiological outcomes.

Purpose: In an era where arthroscopic rotator cuff repair is dominant in the United States (77.9 % preference) compared to open surgery (53.33 %), a shift towards minimally invasive All-Arthroscopic (AA) techniques over classical Mini-Open (MO) repair is emerging. This study explores current trends in shoulder procedures in India and compares functional outcomes and radiological repair integrity between AA and MO techniques, which are understudied in the Indian context. Methodology: In this prospective study, 60 patients (30 in the AA group and 30 in the MO group) with rotator cuff tears underwent assessment. Pre/post-operative clinical evaluations and 12-month follow-ups using UCLA and Oxford Shoulder Score, along with preoperative MRI and postoperative USG, were conducted. Results: At one-year follow-up, the AA group showed better functional outcomes (53.3 % excellent/good vs. 30.0 % in MO). No significant radiological differences (Sugaya grading) were found. Tear size was comparable with no association with functional/radiological outcomes. Conclusion: The AA group demonstrated favourable functional outcomes, matched to MO group findings, which is in accordance with global studies. Despite higher costs, the increasing popularity of AA in India is justified by enhanced results and reduced postoperative discomfort.

Open Intra-articular Distal Femur Fracture with 21 cm Bone Loss Managed by Early Vascularized Fibula Grafting and Antibiotic Loaded Synthetic Calcium Sulfate Beads - A Case Report.

Introduction: Open fractures with massive bone defect presents as challenging clinical scenario in clinical practice. If neglected, this can result in infection, non-union or severe limb length discrepancy. Autogenous vascularized fibula grafting along with stable fixation in the form of internal fixation is a viable option in such situations. Synthetic calcium sulfate is a suitable antibiotic carrier to deliver antibiotics locally to prevent infection. We report the case of an adult male who had an open fracture of the distal femur with segmental bone loss of 21 cm, managed with autogenous vascularized fibula graft and locking plates. We used antibiotic-loaded absorbable synthetic calcium sulfate beads locally during the procedure. Case Report: A 52-year-old male, a known case of uncontrolled diabetes mellitus, presented to the emergency department with a comminuted open intra-articular fracture of the left distal femur with bone loss of 21 cm (arbeitsgemeinschaft fur osteosynthesefragen 33C3) following a road traffic accident. He was initially treated with meticulous debridement and internal fixation with locking compression plate. Considering the massive bone defect of 21 cm, he was planned for fibula grafting at a later stage. After 6 weeks, he underwent vascularized fibula grafting from opposite leg and an additional medial plate to stabilize the graft and augment the initial fixation. He was on regular follow-up in the outpatient department. The fracture united with no signs of infection or residual limb length discrepancy. At the latest follow-up at 7 months, he is walking independently without support and is having a functional range of knee movements. There were no post-operative complications in the right leg from where fibula was harvested. Conclusion: Autogenous vascularized fibula graft together with a locking compression plate is a practical choice in managing open fractures with segmental bone loss. The high concentration of local antibiotic delivery with the help of synthetic calcium sulfate beads helped prevent infection, which is the most dreaded complication associated with open fractures. In addition, the calcium sulfate beads promote endochondral ossification resulting in early bone union.

An unusual case of metaphyseal osteonecrosis of humerus in a post covid patient: a case report.

Osteonecrosis of the metaphysis is often rare as it is a highly vascular region. Here we report an unusual case of non-traumatic osteonecrosis of the humerus predominantly involving the metaphysis in a post covid elderly female. The patient had a pathological fracture of humerus during the post-operative period of intertrochanteric femur fracture surgery. She was evaluated for the causes of pathological fracture and the fracture was managed with hemi replacement of the shoulder because of the extensive bone loss. The pathology here could only be explained as some sequelae of hyper inflammatory state associated with COVID-19 infection. The possible differentials are also discussed here. This case report will help clinicians to consider COVID-19 infection as a cause for non-traumatic osteonecrosis among other reported causes of osteonecrosis.

Emphysematous Osteomyelitis of Tibia - A Rare Case Treated with Antibiotic-loaded Absorbable Calcium Sulfate Beads.

Introduction: Emphysematous osteomyelitis (EO) is an uncommon and deadly pathology characterized by occurrence of intraosseus air within the bone. However, only few of them have been reported. The use of local antibiotic delivery system has proven to be very effective in bone and joint infections as they offer decreased hospital stay and early clearance of infection. To the best of our knowledge, there are no reports on local antibiotic delivery using absorbable synthetic calcium sulfate beads in EO. Case Report: A 59-year-old male with Type II diabetes mellitus, chronic kidney, and liver disease came with pain and swelling over left leg. After blood investigations and radiological evaluation, he was diagnosed to have EO of tibia with unknown source of infection. We successfully treated him with immediate surgical decompression and application of antibiotic impregnated absorbable calcium sulfate beads locally for improved local antibiotic delivery. Following this, he was further treated with culture sensitive intravenous antibiotics and his symptoms resolved. Conclusion: Early diagnosis and aggressive surgical intervention along with local antimicrobial therapy using calcium sulfate beads can offer better outcome in EO. The local antibiotic delivery system can decrease the use of prolonged intravenous antibiotic therapy and long hospital stay.