Evaluating axial alignment and knee phenotypes in a young Indian population, using X-rays converted to three-dimensional bone models, and their relevance in total knee arthroplasty.

PURPOSE: The standard principle of total knee arthroplasty (TKA) targeted by most orthopaedicians is the alignment of the lower limb in a neutral mechanical axis. However, for several patients the neutral mechanical alignment is not normal. Aligning these patients to a neutral mechanical axis may not result in desirable outcomes as it may feel unnatural. This study aimed to discover what percentage of the young healthy Indian population have a neutral hip-knee-ankle angle (HKA = 180°) and what percentage of this population have a deviation from the neutral HKA. We also studied the distribution of knee phenotypes in this non-arthritic population. SUBJECTS AND METHODS: A total of 196 lower limbs were evaluated from 100 subjects, between the ages of 20 and 35 years, without any history of lower limb pathology, of which 50 were males and 50 were females. All volunteers were subjected to full-leg standing anteroposterior and lateral digital radiographs on which various alignment parameters were analysed. Three-dimensional bone models were generated using a validated software. RESULTS: 125 limbs (63.7%) from the total population lay in the range of 180 ± 3°; 7.14% (14/196) of the total limbs had an HKA angle of 180°; 29.5% (58/196) of the total population had a varus alignment, i.e., HKA angle of ≤176° and 6.6% (13/196) had knees in valgus alignment, i.e., HKA angle of ≥184°. Thirty-four percent (33/96) of limbs in men and 25% (25/100) of limbs in women had constitutional varus knees with an alignment of ≤176°; 5.2% (5) of limbs in men and 8% (8) of limbs in women had constitutional valgus knees with an alignment of ≥184°; 67/96 knees in males and 58 knees in females were in the range of 180 ± 3°. CONCLUSIONS: A significant portion of the normal population had limbs that deviated from the neutral HKA. If these subjects were to need TKA in the future, it would not be desirable to restore their alignment to its neutral.

ACL Reconstruction in a Poliotic Limb with Peroneus Longus Graft.

Introduction: Prevalence of polio was very high in India before its eradication, with a number of people living with its residual effects. Anterior cruciate ligament (ACL) injury is the most common knee injury. To the best of our knowledge, this is the first report in literature presenting ACL injury in a poliotic limb and its management. Case Report: A 30-year-old male with poliotic limb and equinovarus deformity presented with ACL injury to the same limb. ACL reconstruction was done using Peroneus longus graft. Postoperatively patient was gradually returned to preinjury activity levels. Conclusion: ACL tears in a poliotic limb can be a challenging case. Proper preoperative planning and anticipation of problems can help in managing the case with a good outcome.

Total Elbow Arthroplasty in Young Patients - An 8-Year Follow-up Case Series.

Introduction: Certain elbow pathologies can give rise to considerable loss of joint function, which would severely affect the daily living activities of the patients. Total elbow arthroplasty (TEA) can be a safe and reasonable motion-preserving and pain-relieving option in such debilitating elbow conditions. The aim of this case series is to evaluate the functional outcome of TEA in young patients with four different indications after an 8-year follow-up. Case Report: We report a case series of four TEA cases done for different indications, namely rheumatoid arthritis, chronic elbow dislocation, post-traumatic elbow ankylosis, and failed primary total elbow replacement, all in relatively young patients. All patients were given a semi-constrained Coonrad-Morrey prosthesis using a posterior Bryan-Morrey approach. The cases were done during the years 2013-2014. Eight-year follow-up of each case showed excellent functional outcome and persistent pain relief with a high Mayo Elbow Performance Score. All the patients have given written consent for publishing this article. Conclusion: Despite being uncommon, total elbow replacement can be the choice of surgery for certain elbow affections, giving satisfactory functional recovery and good pain relief, even in a younger population.

Can "Aseptic" Looking TIBIA Non-union be Result of an Unrecognized Subclinical Infection?

Introduction: The usual cause of a distal tibial fracture is a high-energy trauma. Although multiple options are available for their treatment such as intramedullary nailing, open plating, and external fixator, each of these options might result in a non-union. Knowing the type of non-union not only allows us to guess the cause but also directs us toward the best possible treatment. Despite this, we might still get surprises on the operating table due to pre-operative misdiagnosis. Case Report: Reporting a case of a 42-year-old male with a 15-month-old left distal tibia non-union. The index injury was a grade 1 distal third tibia fibula fracture which was fixed with a plate and screws 15 months back. All the clinical and biochemical signs hinted toward the diagnosis of an aseptic non-union and the treatment was planned accordingly. However, intraoperative findings were much different due to which the surgeons had to improvise and change the intervention to an antibiotic-coated nail. Conclusion: Although each variety of non-union has its set of signs and symptoms, they can be misleading. Different etiologies can coexist making it difficult to give a perfect pre-operative diagnosis and management. Non-unions, especially in the tibia, thus need meticulous understanding of the underlying disease process and extensive treatment strategies.

Femur Shaft Fracture in a Polio Patient.

Introduction: Although poliomyelitis is on the verge of eradication, the survivors of this disease are still living with its complications. Polio survivors with its musculoskeletal complications will continue to be a part of our population for many more decades'. Although poliomyelitis in itself is not common today, fractures in polio affected patients' limbs are a common entity and are difficult to manage with common fracture management protocols. Case Presentation: This study presenting a case of 58-year-old male with alleged history of twisting of the right lower limb while walking. X-rays suggested fracture right shaft femur. Patient had a history of poliomyelitis with the right lower limb affection and had a fixed flexion deformity of 15° at the right knee joint. The patient had to undergo two surgeries. In the first procedure, distal femur plating was done through lateral approach. Due to radiological signs of non-union, in the next procedure, additional medial plate was added and bone grafting was done to ensure stable fixation and union. Conclusion: Treating a fracture in a polio affected limb is a challenging task taking into consideration the previous bony deformity as well as the myopathy. Knowledge of treating these fractures as well as pre-operative planning is important to a trauma surgeon as such scenarios are not very rare.