Combining Platelet-Rich Plasma Instillation With Core Decompression Improves Functional Outcome and Delays Progression in Early-Stage Avascular Necrosis of Femoral Head: a 4.5- to 6-Year Prospective Randomized Comparative Study.

BACKGROUND: Avascular necrosis of femoral head is a debilitating disease frequently progressing to femoral head collapse and joint destruction. The efficacy of core decompression (CD) remains controversial. METHODS: About 40 consecutive age-matched and gender-matched patients (53 hips) were randomized into 2 groups by computer-generated algorithm table in a prospective randomized double-blinded comparative study. Group A (platelet-rich plasma [PRP] with CD) included 19 patients (25 hips), and group B (CD only) included 21 patients (28 hips). Postoperative Harris Hip Score and magnetic resonance imaging to quantify the necrotic area by using modified Kerboul angle were done and evaluated. Mean follow-up was 64.3 months (range, 54-72) and 63.7 months (range, 56-72) in groups A and B, respectively. RESULTS: There was statistically significant difference between PRP and control groups in pain score (P = .00), functional score (P = .02), and Harris Hip Score (P = .00) at final follow-up. There was no progression in stage 1 disease. Stage 2 disease showed 24% progression in group A and 43% progression in group B. The difference was statistically significant (P = .025). Survivorship from femoral head collapse, any procedure, and total hip arthroplasty was 84%/68% (P = .00), 76%/57% (P = .02), and 92%/78% (P = .01) in 2 groups, which was statistically significant. CONCLUSION: PRP use after CD provides significant pain relief, better midterm functional outcome, retards the progression, and enhances the survivorship free from reoperation for hip arthroplasty and femoral head collapse in early stages of avascular necrosis of hip than CD alone.

Topical vs Intravenous Tranexamic Acid in Reducing Blood Loss After Bilateral Total Knee Arthroplasty: A Prospective Study.

BACKGROUND: Total knee arthroplasty (TKA) results in substantial postoperative blood loss with increased morbidity. Despite various studies proving the efficacy of tranexamic acid (TXA), no consensus exists on the routes of administration. METHODS: Seventy consecutive patients with knee arthritis undergoing simultaneous bilateral TKA, who were eligible and fulfilled the criteria, were taken up for this study. They were randomly allocated by a computer-generated random number table, either to receive intravenous TXA (IVTXA; group 1) or topical TXA (TTXA; group 2) in a prospective, double-blinded study. The primary outcome measures were total blood loss and total drain output. The secondary outcome measures were number of blood units transfused and clinical and functional outcomes as evaluated by the Knee Society Score, Western Ontario and McMaster Universities Arthritis Index score, visual analog score, and wound score. RESULTS: Both groups were similar in age, sex, and body mass index, and no statistical significance was observed. There was statistically significant difference between IVTXA and TTXA groups in mean postoperative total blood loss (P < .001), postoperative hemoglobin (P < .001) with a higher drop of hemoglobin in the former, total drain output (P < .001), and allogeneic blood transfusion (P < .001). No complication was observed in either group. Significant difference was observed in the Western Ontario and McMaster Universities Arthritis Index score at 12 weeks and 6 months (P = .015 and .007) and Knee Society Score at 6 and 12 months (P = .050 and .045, respectively). However, no significant difference was found at 6 weeks. CONCLUSION: TTXA is better than IVTXA in reducing blood loss and clinical outcome after simultaneous bilateral TKA.

Platelet-rich plasma prevents blood loss and pain and enhances early functional outcome after total knee arthroplasty: a prospective randomised controlled study.

PURPOSE: The purpose of this study was to determine whether platelet-rich plasma (PRP) might prevent blood loss and postoperative pain and expedite wound healing following total knee arthroplasty (TKA). METHODS: Forty consecutive patients with knee arthritis who were matched for age, sex and body mass index (BMI) were randomly allocated to either receive or not receive PRP application over the wound, including capsule, medial and lateral recesses, during TKA. Postoperative haemoglobin, blood loss, blood transfusion, visual analogue scale (VAS) score, wound score, Knee Society Score (KSS) and Western Ontario and McMaster Osteoarthritis Index (WOMAC) score were recorded and evaluated. RESULTS: The platelet-rich plasma and control groups comprised 17 and 23 patients, respectively. The PRP group recorded significantly less reduction in haemoglobin and need for blood transfusion (p = 0.00 and p = 0.001, respectively), experienced less pain (p = 0.00) and required fewer narcotics than the control (p = 0.00). There was significant difference in range of motion (ROM) at three months (p = 0.01), no significant difference in wound scores (p = 0.311) and significant difference in KSS and WOMAC scores at 12 weeks (p = 0.00, 0.00). However no significant difference was found at six months. CONCLUSIONS: PRP has significant effect in preventing blood loss, postoperative pain and need for narcotics after TKA and has a positive effect on short-term clinical outcome.

Femoral head fracture without hip dislocation.

Femoral head fractures without dislocation or subluxation are extremely rare injuries. We report a neglected case of isolated comminuted fracture of femoral head without hip dislocation or subluxation of one year duration in a 36-year-old patient who sustained a high energy trauma due to road traffic accident. He presented with painful right hip and inability to bear full weight on right lower limb with Harris hip score of 39. He received cementless total hip replacement. At latest follow-up of 2.3 years, functional outcome was excellent with Harris hip score of 95. Such isolated injuries have been described only once in the literature and have not been classified till now. The purpose of this report is to highlight the extreme rarity, possible mechanism involved and a novel classification system to classify such injuries.

Predictors of posterior cruciate ligament degeneration in osteoarthritic knees.

PURPOSE: To evaluate the tibial articular cartilage and histology of the posterior cruciate ligament (PCL) in osteoarthritic knees so as to determine predictors of PCL degeneration. METHODS: 23 advanced osteoarthritic knees (mean patient age, 61 years) treated with total knee arthroplasty (TKA) were prospectively studied. The Knee Society Score was assessed. Osteoarthritic changes on radiographs were graded as mild, moderate, or severe. Tibial articular cartilage erosion was assessed. The appearance of both cruciate ligaments was classified as normal, abnormal (thinner and sclerotic), or ruptured. Both ligaments were examined histologically for degenerative changes. Each degenerative change of the PCL was graded by 2 histopathologists twice separately. Higher scores indicated more severe degeneration. RESULTS: Of the 23 knees, the gross appearance of the anterior cruciate ligaments (ACLs) was normal in 6, abnormal in 11, and ruptured in 6. Histologically, the PCLs were normal in 4, minimally degenerated in 2, mildly in 8, moderately in 5, and severely in 4. The predominant degenerative change was the presence of loose fibrous tissue. ACL appearance correlated positively with PCL degeneration (r=0.883, p=0.001). The mean Knee Society Score was 24 (range, 0-43), and the mean function score was 30 (range, 5-55). PCL degeneration correlated positively with the Knee Society Score (r=0.565, p=0.02) but not with the function score (r=0.061, p=0.447). Anteroposterior instability correlated positively with PCL degeneration (r=0.691, p=0.01). Erosion in the lateral tibiofemoral compartment and ACL insufficiency were indicators of PCL degeneration (despite a normal appearance). Inter-observer reliability and intra-observer reproducibility were 0.82 and 0.87, respectively. CONCLUSION: The Knee Society Score, anteroposterior instability, ACL appearance, and erosion in the lateral tibiofemoral compartment are predictors of PCL degeneration and can help decide on the optimal type of TKA implant (PCL-retaining vs. PCL-sacrificing design).

Mobile vs fixed-bearing total knee arthroplasty performed by a single surgeon: a 4- to 6.5-year randomized, prospective, controlled, double-blinded study.

The superiority between posterior-stabilized mobile-bearing and fixed-bearing designs still remains controversial. Fifty-six consecutive patients undergoing primary, unilateral knee arthroplasty for osteoarthritis were randomly assigned to receive either a mobile-bearing (29 patients) or fixed-bearing (27 patients) prosthesis. We report the results at 4 to 6.5 years (mean, 5.5) follow-up. The Knee Society knee scores, pain scores, functional scores and Oxford knee scores were not statistically different (P > 0.05) between the two groups. Mean postoperative range-of-motion of mobile-bearing knees was significantly greater than that of fixed-bearing knees (127º versus 111º, P = 0.011). 72% of patients could sit cross legged, 48% could sit on the floor, and 17% could squat. Kaplan-Meier survival rate was 100%. No spin-out of mobile bearing was observed. The radiological analysis showed no osteolysis or implant loosening.

Anatomical considerations for safe scapular resection in snapping scapula syndrome.

BACKGROUND: The resection of the superomedial angle of the scapula in snapping scapula syndrome is associated with potential risk of injury to the suprascapular nerve. The aim of the present study was to determine the distance of site of resection on the upper border of the scapula from the suprascapular notch during arthroscopic resection of the superomedial angle using standard superior Bell's and medial portals at the middle of medial border. MATERIALS AND METHODS: The study was conducted on 92 intact dry adult scapulae of unknown sex. The junction of the medial two-thirds and the lateral one-third of an imaginary line joining the superomedial angle and the lateral margin of the acromion was marked as superior Bell's portal. The middle of the medial border was considered as the arthroscopic resection target. The site of resection on the upper border was found out with the help of these two points and other relevant measurements were also taken. RESULTS: The distance between the suprascapular notch and the lateral edge of resection on the upper border of the scapula was more than 10 mm in 85.9% cases and less than 10 mm in 14.1%. A statistically significant positive correlation was found between this distance and the distance between the superior angle and acromion angle of the scapula. CONCLUSION: Our study suggests that during arthroscopic resection using superior Bell's portal and medial portal, suprascapular notch hence the suprascapular nerve would have safe margin of more than 10 mm from the resection site on upper border in 85.9% cases and would be vulnerable to injury in 14% cases. The procedure would be safer in patients with a wider scapula.

Variable osseous anatomy of costal surface of scapula and its implications in relation to snapping scapula syndrome.

BACKGROUND: Variation in normal anatomy of costal surface of scapula may disrupt smooth scapulothoracic movements and may cause snapping scapula. The aim of this study was to assess variable anatomy of costal surface of scapula and its role in etiopathogenesis of snapping scapula syndrome. MATERIALS AND METHODS: Superomedial angle, depth of costal surface, forward angulation of root of coracoid process and thickness of superior and inferior angles of 92 dry intact adult scapulae of unknown sex were studied. RESULTS: Superomedial angle ranged from 124° to 162° (144.34° ± 9.09°). The forward angulation of root of coracoid process ranged from 120° to 160° (141.60° ± 6.53°). Depth of costal surface at the level of root of spine varied widely between 10.5 and 26.7 mm (16.73 ± 3.367 mm). Thickness of superior and inferior angles measured 3.34 ± 0.87 and 6.71 ± 1.18 mm, respectively. Forwardly bent rhinoceros-horn-like projection at the lateral border of scapula was seen in 2.17% of specimens. CONCLUSION: Variation in anatomy of costal surface of scapula observed in this study may be clinically significant with respect to snapping scapula syndrome.

Anatomical variation in formation of brachial plexus and its branching.

Variant brachial plexus formation with two trunks and two cords is uncommon and has clinical implications as it may result in failure of regional brachial or axillary block. During routine anatomical dissection, unilateral variation in the formation of brachial plexus accompanied by unusual positional relationship with axillary artery was discovered in the left upper extremity of a 52-year-old Indian male cadaver. Brachial plexus showed two trunks formed by ventral rami of C5, C6 and C7, C8, T1 spinal nerves, respectively, which first split and then reunited in an unusual manner to form two cords: posterior and lateral instead of three. Medial cord was absent. The branching pattern of the brachial plexus also showed important variations. Second part of axillary artery was found lying inferomedial to brachial plexus instead of passing between medial and lateral cords. Transverse cervical artery was found to be coursing between two trunks instead of passing superficial to brachial plexus. Median nerve was observed to be formed from a single root, instead of usual two roots. Embryologically, this rare variation may be due to the development of axillary artery from ninth segmental artery instead of usual seventh cervical intersegmental artery. Such rare variation is clinically important as this knowledge may help the anesthesiologists and the surgeons to avoid any inadvertent damage to nerves and axillary artery during blocks and surgical interventions.

Anatomic consideration of caudal epidural space: a cadaver study.

The knowledge of sacral hiatus anatomy is imperative in clinical situations requiring caudal epidural block for various diagnostic and therapeutic procedures of the lumbosacral spine to avoid failure and dural injury. In this study, a detailed anatomic study of the sacral region was carried out on 49 male adult Indian cadavers. Dorsal surface of sacral region was dissected to study sacral cornua, sacral hiatus, and the dimensions of triangle formed by the right and left posterosuperior iliac spines with apex of the hiatus. Midsagittal sections were subjected for various anatomical measurements. The angle of needle insertion and the depth of caudal space were noted. Cornu was not palpable bilaterally in 7 (14.3%) and palpable unilaterally in 12 (24.5%) specimens. Mean (standard deviation) distance between apex of hiatus and coccyx tip was 57.5 (8.7) mm and length of sacrococcygeal ligament was 34.2 (7.4) mm. The dimensions of the triangle were found to be interchangeable in 25 cadavers. Once the needle is introduced into the canal after penetrating the sacrococcygeal ligament, it should not be advanced >5 mm to prevent dural puncture. The level of maximum curvature of sacrum was S3 in 34 (69.4%) of cases. The dural sac was found to terminate at S2 in 41 (83.6%). The mean (SD) angle of depression of the needle was 65.7 (5.5) (range 58-78). The measurements described for the identification of the sacral hiatus, optimal angle of depression, and depth of the needle may improve the safety and reliability of a caudal epidural block.

Hybrid external fixation in periarticular tibial fractures. Good final outcome in 56 patients.

Out of 65 patients with periarticular fractures of the tibia treated by use of hybrid external fixation (a combination of indigenously manufactured version of ring and AO tubular fixator) from February 1997 to October 2003, 56 cases were taken up for this study with a minimum follow-up of 12 months. The injury was due to a high-velocity motor vehicle accident in 49 and a fall in 7 patients. Thirty five were tibial plateau fractures and 21 were distal tibial plafond fractures. Forty eight were compound fractures and eight were closed. They were treated by debridement (48 compound) and hybrid external fixator (n = 56). All the patients were assessed clinically and radiographically for an average follow-up of 42.5 months (range: 12 to 67). In tibial plateau fractures (n = 35), the final outcome was good to excellent in 30, fair in 2 and poor in 3. In tibial plafond fractures (n = 21), results were good to excellent in 16, fair in 3 and poor in 2. We recommend the use of hybrid external fixator for periarticular tibial fractures occurring due to high-energy trauma. In addition, rates of complications as seen with other modalities of fixation are greatly reduced. It facilitates adequate care of associated soft tissue injuries.