"New innovative QR code-based mobile audience response system (mARS) for panel discussion (PD) in a Indian Arthroscopy Society conference(IASCON) of 1102 registered delegates." - A cross-sectional study.

Purpose: The purpose is to determine the feasibility of Mobile based Audience response system (mARS) and the best time to get maximum delegate participation in panel discussion at a national Indian Arthroscopic Society conference(year-2022) with 1102 delegates by studying their engagement at various time schedules. Methods: Our institution-based software engineer set up mARS, and a separate URL, was purchased for recording the responses. 5 Panel discussions (PD) were moderated by senior national faculty, 3 were on knee topics, and 2 were on Shoulder topics. The audiences were engaged in ongoing PD discussion by displaying the multiple choice questions (MCQs) questions for 15-30 seconds & real-time response was collated, and poll results were declared in real-time during the conference. The data of each panel discussion was acquired from admin page & statistical analysis was done to determine the audience participation in Hall A (Knee) versus Hall B (Shoulder), Day 2 versus day 3 and pre-lunch session versus post-lunch session. Results: Maximum number of delegates (252) participated in Multi-ligament knee injury (MLKI)PD (day 2); however, percentage of response was higher for Massive cuff tear PD (day 3). Audience response was better on day 2, for shoulder topics and pre-lunch session PD than on day 3, knee topics and post-lunch sessions & this was statistically significant (p < 0.001). Conclusions: mARS proves is an innovative and valuable resource, enhancing audience participation during PD at large gatherings. Real-time results aids not only active delegate engagement but also helps moderators/panellist in curating discussions to answer uncommon queries and unify the responses. The most suitable time for PD sessions utilizing mARS is the pre-lunch slot on day 2. Level of the evidence: Level 3 (Decision Analysis- Observational cross-sectional study). Study design: Cross-Sectional Study. Relevance: This article helps the organizers of larger meeting to time the panel discussion appropriately to obtain maximum audience participation and curate the discussion based on delegate centric responses. Key terms: mobile Audience response system (mARS), Audience response system (ARS), Panel Discussion(PD), Indian Arthroscopic Society conference (IASCON), Indian Arthroscopy society (IAS). What is known about the subject: Audience response system (ARS) in the smaller meeting and webinars are well known entity to have active participation in on-going discussion. "What are the new findings?": Response and results of innovative QR code-based mobile Audience response system (mARS) for Panel discussion (PD) in larger arthroscopic conference with 1102 delegates showed delegates were more interested in Shoulder topics and pre-lunch session and Day 2 response were better.

"Foot peak pressures are comparable to normal foot after flexor hallucis longus transfer for chronic retracted tendo-achilles tear: A pedobarographic analysis of normal foot versus affected foot".

INTRODUCTION: Foot pressure changes and morbidity after flexor hallucis longus (FHL) transfer in chronic retracted tendoachilles (TA) tears have not been documented. The primary aim of our study is to analyze the peak pressure changes in various zones of the foot at each successive follow-up in the affected foot versus normal foot. The secondary aim is to determine FHL tendon healing and muscle hypertrophy. METHODS: This is a prospective study of 46 patients who underwent FHL augmentation for chronic retracted TA tears (between 2019 and 2022). Included TA tear > 6 weeks duration and retraction > 2.5 cm. Excluded open TA tear, < 6 weeks and retraction < 2.5 cm. Depending on the amount of retraction, FHL augmentation combined with TA repair/VY plasty/turn-down-plasty. Functional outcome was analyzed with AOFAS hallux metatarsophalangeal scale. Pedobarographic analysis was done pre-operatively and at 3, 6, 9 months, 1 year and at the final follow-up. Parameters studied included forefoot peak pressure (FFPP), hindfoot peak pressure (HFPP), great toe peak pressure (GTPP), first Mmeta-tarso phalangeal peak pressure (MTPP), area under the pedobarograph and maximum force. At final follow-up MRI was done to assess FHL healing and hypertrophy. Statistical analysis was done for these parameters using appropriate tests. RESULTS: Study involved 29 male and 17 female patients, mean age 49.5 years (33-65 years) and mean follow-up 26.8 months (14-38.4months). Mean hallux MTP-AOFAS score increased from 46.04 ± 7.31 preoperatively to 96.17 ± 3.22 at the final follow-up (P < 0.01). There was gradual improvement noted in FFPP, GTPP, MTPP Peak pressures at subsequent follow-ups, and by the end of 1-year foot pressures were comparable to normal side FFPP (8.02 ± 3.8 N/cm2 to 31.35 ± 3 N/cm2), GTPP(30.78 ± 13.01 N/cm2 to23.17 ± 7.5 N/cm2), MTPP(5.22 ± 2.64 N/cm2 to 23.3 ± 9.6 N/cm2). Initial high HFPP showed decline in subsequent follow-up and restored back to normal HFPP (36.91 ± 5.7 N/cm2 to 25.09 ± 3.7 N/cm2). Changes in pressures were statistically significant (< 0.001). Six patients had superficial wound infections healed with antibiotics. 23 patients who underwent a post-operative MRI showed a mean of 27 mm muscle thickness and 7.1 mm tendon thickness with complete incorporation of the FHL. CONCLUSION: Foot peak pressures though initially deranged, are restored and comparable to normal foot after FHL transfer for chronic retracted TA tear. FHL hypertrophy is observed at the muscle thickness and at the distal tendon and provides adequate strength to repair and restore foot pressures. LEVEL OF EVIDENCE III: Prospective comparative study (normal versus operated foot).

Neglected Desmoplastic Fibroma of calcaneum with collapsed hindfoot, restored with allograft transplantation: A rare case report.

Desmoplastic fibroma of the calcaneum is a rare, locally aggressive tumour. A 24-year-old female presented with long-standing heel pain, with the collapse of the calcaneum (hindfoot) that was untreated for 7 years. Eradication of this locally aggressive lesion by adjuvant therapy and restoration of calcaneal bony morphology by allograft was an arduous and challenging task. At the final follow-up, the heel was painless, and the patient could walk normally without support. Conclusion: Restoration of calcaneal height is challenging in young patients, and using structural allograft restores calcaneal and hindfoot morphology. Patient education about the high chances of recurrence despite surgical clearance is essential, and intraoperative adjuvant usage can reduce the recurrence.

Inconclusive evidence that arthroscopic techniques yield better outcomes than open techniques for subtalar arthrodesis-A systematic review.

IMPORTANCE: Open in situ subtalar arthrodesis (ISTA) has been a standard procedure for treating subtalar arthritis for varied etiologies with good outcomes. There has been a paradigm shift from ISTA to arthroscopic subtalar arthrodesis (ASTA) over the past two decades due to increase in number of surgeons performing arthroscopy worldwide. However, there is only limited evidence in the existing literature to substantiate the benefit of this change with regards to patient benefit. To our knowledge, there are also no systematic reviews comparing the results of the two techniques for subtalar arthrodesis (STA). AIM: Our systematic review aims to determine the superior technique for performing STA by comparing the outcomes, union rates, and complications between open and arthroscopic approach for in situ STA. We hypothesised that both procedures would have similar outcomes, union rates, time to union, and complication rate for in-situ STA. EVIDENCE REVIEW: Three databases, MEDLINE/PubMed, the Cochrane Library, and Google Scholar, were searched using predefined inclusion and exclusion criteria to compare the two procedures. Risk of bias assessment was done using The Risk of Bias in Non-randomised Studies of Interventions (ROBINS-I) tool for assessing the risk of bias in the included studies. Weighted mean averages were computed for all parameters and tabulated separately for ASTA and ISTA. FINDINGS: We included a total of 22 studies with a total of 978 (ASTA-310, ISTA-668) patients in the review. The most common indication for both techniques was post traumatic subtalar arthritis due to malunited calcaneal fracture in both groups (54.5%). The American Orthopaedic Foot & Ankle Society score was better in the ASTA group with a weighted average improvement of 43.4, while the weighted average improvement was 31.1 in the ISTA group, respectively. Patients undergoing ASTA had a weighted average union rate of 95.5% (standard deviation [SD]-3.6) with a weighted average time to union of 12.2 weeks (SD-2.4) while the ISTA group reported 90.7% (SD-6) union rate with a weighted average time to union of 15.5 weeks (SD-8.4). The weighted overall average complication rate was 13.1% (SD-8.9) in ASTA group and 20.3% (SD-16.2) in the ISTA group with hardware-related complications being the most common in both the groups. CONCLUSION: From the existing literature, our review suggests that both ASTA and ISTA techniques are effective procedures for STA. However, there is no conclusive evidence to recommend one technique over another. High quality randomised studies may be further required to clearly define the superiority of one technique over another LEVEL OF EVIDENCE: level III.

Concomitant Patellar Tendon Tear (PTT) with Cruciate and/ Collateral ligament injury (Multi- Ligamentous Knee Injury -MLKI) and new pathoanatomical -Ganga PTT classification aids to strategize treatment options.

INTRODUCTION: Concomitant patellar tendon (PT) tear with cruciate or multi-ligament knee injuries (MLKI) following high-velocity injury requires a systematic approach. METHODS: The study is a retrospective case series of patients (2008-2019) with concomitant PT ligament injury with cruciate or collateral ligament injury (MLKI), including bony avulsion injuries. Isolated cruciate and MLKI without patellar tendon tears are excluded. N = 32 patients (1 female and 31 male) are divided into two groups, Group 1 (11 patients) with PT tear and ACL tear and group 2 (21 patients) with PT tear and MLKIs. Patients were taken up for a single stage in types 1,2,3 and staged repair with reconstruction for types 4,5 of our new classification. All the patients are followed up regularly, and IKDC and Lyshom's score and objective radiological stress x-rays taken at each follow-up RESULTS: Incidence of PTT combined injuries among all knee ligament injuries is 0.57%. The mean age was 35.09+/-11.96 SD(group1) and 36.55+/-11.89 SD(group2). The average follow-up was 34.45 months +/- 12.86SD (group 1) and 35.3 months +/- 15.75 SD (group2). Mean post-operative Lysholm score and IKDC score of group 1 and group 2 improvement was statistically significant p-value <=0.01. The mean post-operative ROM of the two groups were 132.73 (SD 6.46) (Group 1) and 111.75 (15.75) (Group 2) and was a statistically significant p-value <0.01. Residual lag of 30° seen in all patients improved by 3rd month in group 1 and 6th month in group 2. Knee stiffness is seen in 2 patients and superficial infection in 2 patients. CONCLUSION: PTT combined injuries are rare and occurs due to direct impact injuries. Single-stage PT repair with ACL reconstruction gives adequate stability, and extensor lag is eminent and needs supervised rehabilitation. PT with MLKI is a challenging scenario that can be performed in single-stage/multiple stages, depending on the injuries, surgical expertise, and institutional facilities. Newer simplified classification aids surgeons in planning a treatment strategy.

Concomitant Medial Meniscal Root Repair with Extrusion Repair (Centralization Technique).

Background: Meniscal extrusion is a phenomenon in which a degenerative posterior horn tear, radial tear, or root tear results in displacement of the body of the meniscus medial to the tibial rim. The paramount function of the meniscus is to provide load distribution across the knee joint. Meniscal extrusion will prevent the meniscus from properly fulfilling this function and eventually leads to progression of osteoarthritis1. Thus, root repair accompanied by arthroscopic meniscal extrusion repair (by a centralization technique) has been suggested for restoration of meniscal function2-5. There are various techniques to correct meniscal extrusion, including a dual-tunnel suture pull-out technique2 (to address extrusion and root tear2), a knotless suture anchor4,6 technique, and an all-inside suture anchor repair7. The indications for extrusion repair are not consistently reported in the literature, and the procedure is not always easy to perform. Currently, there is no consensus regarding the ideal technique. In the present article, we describe the steps for successful combined medial meniscal root repair with extrusion repair and centralization. Description: Place the patient in the supine position with the knee supported in 90° of flexion and the feet at the edge of the operating table with foot-positioner support. First, meniscal root repair is performed with use of the suture pull-out technique, utilizing a cinch suture configuration to hold the root in place, and the suture tapes are fixed over the anterior cortex of the tibia with a suture button. Next, the meniscal body is arthroscopically assessed for residual extrusion from the medial tibial rim. Extrusion repair is indicated in cases with >3 mm of extrusion7-9, as measured on magnetic resonance imaging. In our technique, any extrusion beyond the medial tibial rim is reduced and secured with use of a double-loaded 2.3-mm all-suture type of anchor. Alternatives: Alternatives include surgical procedures in which the root repair is performed with use of suture-anchor fixation10,11 and the extrusion repair is performed with use of the transtibial suture pull-out method. Rationale: Root repair performed with the most common fixation techniques does not always reduce meniscal extrusion or restore meniscal function12,13. Consequently, several augmentation techniques have been reported to address meniscal extrusion3,14, including those that use arthroscopy to centralize the midbody of the meniscus over the rim of the tibial plateau. The rationale for this combined procedure is to restore the hoop-stress distribution and maintain meniscal function by repairing the extrusion of the meniscus. Addressing all intra-articular pathologies in a single stage is a challenging situation, and the sequence of the repair is important to achieve optimal postoperative results. Expected Outcomes: Several surgical techniques have been described for the operative treatment of extrusion repair with use of centralization sutures2,3,5,6, and each has its own distinctive pearls and pitfalls for each. To combine root repair and extrusion repair presents a challenge for surgeons. From our clinical experience, a methodical approach to understanding the pathoanatomy and sequential execution of repair techniques would yield desired results. Extrusion correction through the use of a peripheral suture anchor over the medial rim of the tibia and knot tying are relatively easier to perform than some other published extrusion-repair techniques. Although no consensus has been achieved yet regarding the best technique, recent literature has suggested that the use of centralization sutures is effective to restore the native biomechanical properties of the medial meniscus5.Mochizuki et al. assessed the clinical and radiological outcomes of combined medial meniscal root repair and centralization in 26 patients with a minimum follow-up of 2 years. Both Lysholm scores and Knee injury and Osteoarthritis Outcome Scores improved significantly after surgery, with a significant reduction in extrusion distance from preoperatively to 2 years postoperatively20. Koga et al21 assessed the 2-year outcomes of lateral arthroscopic meniscal centralization, finding significantly reduced meniscal extrusion at both 3 months and 1 year postoperatively. Biomechanical studies have demonstrated that centralization can improve meniscal mechanics and potentially reduce the risk of osteoarthritis. The centralization suture technique for extrusion repair has the theoretical advantage of restoring meniscal function following meniscal root repair; however, there are also concerns regarding over-constraint of the meniscus. We believe that the medial meniscus, being less mobile than the lateral meniscus, can withstand the constraint created by the use of centralization. Meniscal centralization is a technically demanding surgical procedure, but with a systematic approach and meticulous technique, we have observed good short-term outcome in our patients. Important Tips: A tight medial compartment is one of the most common problems encountered during a medial meniscal root repair. "Pie-crusting" of the superficial medial collateral ligament at the tibial insertion aids in improving the space, thereby reducing chondral damage during the root repair.It is challenging to achieve the correct inclination of insertion when inserting the suture anchor through a mid-medial portal. This limitation can be mitigated by utilizing a 16G or 18G needle before making the portal, as the needle direction, trajectory, and extent of accessibility within the joint will aid in proper portal placement and anchor insertion.Suture management is another technical challenge. Suture tape is first cinched to the root of the meniscus and then shuttled into the transtibial tunnel in order to discern the reducibility of the meniscus and the extent of possible extrusion correction. Then, extrusion repair is performed. This sequence allows the surgeon to avoid mixing of root-repair sutures and extrusion-repair sutures. Following insertion of the all-suture anchor, each suture limb is brought out through the anteromedial portal, passed through the nitinol loop from the lasso, and shuttled back through the mid-medial portal. Knot tying is performed through the mid-medial portal. Acronyms and Abbreviations: ACL = anterior cruciate ligamentPCL = posterior cruciate ligamentICRS grading = International Cartilage Research Society system for classification of cartilage lesionsKL grade = Kellgren-Lawrence system for classification of osteoarthritisMRI = magnetic resonance imagingMC = medial femoral condyleMPTA = medial proximal tibial angleLC = lateral femoral condyleHTO = high tibial osteotomyMCL = medial collateral ligamentAM = anteromedialKOOS = Knee injury and Osteoarthritis Outcome ScoreMME = medial meniscus extrusion.

Outside-in technique versus inside-out semitendinosus graft harvest technique in ACLR: a randomised control trial.

BACKGROUND: Paraesthesia after hamstring graft harvest is a ubiquitous complication in the early post-operative period, and its correlation with vertical versus horizontal skin incision are well documented. The purpose of the study is to evaluate the incidence and extent/area of sensory loss of saphenous nerve branches occurring with the outside-in (OI) versus inside-out technique (IO) of semitendinosus graft harvest from the sartorius fascia and to determine a better method of graft harvest. METHODS: Sixty patients who underwent isolated semitendinosus graft harvest during anterior cruciate ligament reconstruction (ACLR) between 2016 and 2017. Patients were randomised into two groups depending on the graft harvest technique: 30 in the OI group and 30 in the IO group. The area of sensory loss was mapped on the patients' skin using tactile feedback from the patients at each follow-up (10 days, 1 month, 3 months, 6 months and 1 year). Then, the area of sensory changes for the infrapatellar branch (IPBSN) and sartorial branch (SBSN) of the saphenous nerve, incision length, graft harvest duration, and graft length were analysed statistically between the groups. RESULTS: In groups 1 and 2, 18/30 (60%) and 19/30 (63%) of patients, respectively, developed sensory changes, with no significant difference between the groups (p = 0.79). Isolated SBSN and IPBSN paraesthesia occurred in 2/60 (3%) and 19/60 (32%), respectively. Combined SBSN and IPBSN paraesthesia was present in 16/60 (27%) of patients. There was no significant difference in the area of the sensory deficit between OI and IO groups on the 10th post-operative day or at 1-month, 3-month or 1-year follow-up (p = 0.723, p = 0.308, p = 0.478, p = 0.128, respectively). However, at 6-month follow-up, the area of paraesthesia was significantly higher in the IO group (p = 0.009). The length of incision and duration of graft harvest was higher in the OI group than in the IO group (p = 0.002 and p = 0.007, respectively), and the total length of the graft was greater in the IO group (p = 0.04). CONCLUSION: Incidence is equally distributed, area of iatrogenic saphenous nerve injury gradually decreases, and recovery is seen in the majority of the patients in both graft harvest techniques. IO graft harvesting technique is better in terms of graft harvest time and cosmetics and yields longer graft; however, area of paraesthesia, though not significant, was two-fold higher than the OI technique at 1-year follow-up. CLINICAL RELEVANCE: IO graft harvest technique would enable the surgeon to adopt quicker graft harvest, smaller surgical scar and lengthier graft than the OI technique. LEVEL OF EVIDENCE: Therapeutic randomised controlled prospective study, Level II.

Insertional versus non-insertional tendoachilles tears: a comparative analysis of various predisposing factors and outcome following a repair.

BACKGROUND: Association of tendon degeneration, pre-existing posterior heel pain, Haglund's bump, retrocalcaneal spur, and mode of injury varies for the insertional and non-insertional type of tendoachilles tears (TA). PURPOSE: The study compares the various predisposing factors that determine the distinct type of TA tear and the outcome following a repair. METHODS: This is a retrospective study of the patients who underwent tendoachilles repair during January 2012-June 2018. Patients above 18 years with a minimum follow-up of two years were included. Patients with calcaneal tuberosity avulsions, prior surgeries, and open injuries were excluded. Patients were divided into groups 1 (insertional tears (IT)) and 2 (non-insertional tears (NIT)), and further subdivided based on the tendon degeneration (as D-degenerative and N-normal sub types) from ultrasound findings. AOFAS score and predisposing factors like degeneration, posterior heel pain, Haglund's bump, spur, and mechanism of injury were compared between the groups. RESULTS: The study included N = 146 with a mean age of 51.6 years and mean follow-up of 38.6 (range 24 to 96) months. IT associated with degeneration (IT-D) had a trivial fall as the predominant mechanism (P < 0.001). All patients had significant postoperative improvement of scores with no significant difference between the groups (P = 0.59) and subgroups (P = 0.27).75.34% had degenerative tendon, of which 64.5% were in the IT group and the rest in the NIT group (P = 0.02). 51.4% patients had a Haglund bump in the IT group and n.s. (P = 0.9). Forty-seven percent of patients had pre-existing posterior heel pain, 68% in IT and 32% in NIT (P = 0.04). Subgroup analysis revealed 65% of patients were in the IT-D subgroup (P < 0.001). CONCLUSION: Predisposing factors like posterior heel pain, tendon degeneration, and trivial trauma have a strong propensity for insertional TA tear. In contrast, the prominence of Haglund's bump does not predispose to a distinct type of TA tears. The outcome following a surgical repair-yields good results with no difference between the two groups.

Correlation of factors affecting correction of meniscal extrusion and outcome after medial meniscus root repair.

INTRODUCTION: Meniscus extrusion in medial meniscus posterior root tears (MMPRT) is a consistent MRI finding and correction of extrusion is a primary objective of the meniscal root repair. The purpose of the study is to evaluate feasibility of correction of extrusion and correlation of various factors affecting the postoperative extrusion correction and outcomes in all degenerative medial meniscus posterior roots (MMPRTs). METHODS: A retrospective study of patients who presented with degenerative MMPRTs following trivial incident (Jun 2014 and Aug 2018) and included isolated Laprade type 2 root tear with extrusion in MRI. Patients with ligament injuries, tricompartmental arthritis, malalignment (> 50) and irreparable meniscal tears excluded. All patients underwent arthroscopic trans-tibial tunnel suture pull-out repair. A screening MRI was taken at a 6-month follow-up and functional scores (IKDC and Lysholm's) at final follow-up. The effects of age, gender, duration of symptoms, hip-knee-ankle angle on weight-bearing X-rays, ICRS grading of cartilage status, and MRI data (extrusion distance, tunnel location and healing status of meniscus) on outcomes were analysed. RESULTS: MMPRT (n = 54) with a mean follow-up of 34.6 months (24-48). Mean functional outcomes improved postoperatively IKDC (43.40 ± 5.16-78.65 ± 5.11, p < 0.001) and Lysholm's (65.27 ± 4.28-83.16 ± 4.83, p < 0.001) scores at final follow-up. 57.4% (31) had good correction of extrusion, 3.7% (2) no correction and 38.8% (21) showed increase in extrusion postoperatively. Of all the factors we explored, age, ICRS (low grade) and knee varus (less 2.5 degree) affected extrusion correction. Patients with healed (41 patients), partially healed (9 patients) and anatomic tunnel placement (46 patients) had better extrusion correction than those with non-healing (4 patients) and non-anatomical tunnel (8 patients). CONCLUSION: Patients younger than 50 years, with low grade cartilage damage (ICRS 1, 2), lower KL grade and varus alignment (< 2.50) had good correction of extrusion. Correction of extrusion/progression of extrusion did not influence the clinical outcome at the short-term. The progression of meniscal extrusion is inevitable even after successful repair in elderly and high-risk patients. STUDY DESIGN: Retrospective Case series, level of evidence IV.

Single-Stage Arthroscopy-Assisted Reduction and Internal Fixation (ARIF) of Tibial Rim Fracture With Posterior Cruciate Ligament Reconstruction and Repair of Posterolateral Complex and Meniscal Injury.

Multiligament knee injury with periarticular fractures are high-velocity injuries and generally require a staged treatment approach that involves multiple hospitalizations and results in delayed return to activity. We report a single-stage management technique for these injuries with arthroscopy-assisted reduction and internal fixation of a depressed tibial rim fracture with concomitant posterolateral complex repair, medial meniscal repair, and posterior cruciate ligament reconstruction.

Meniscal Root Repair Along with Auxiliary Procedures for Joint Preservation: Current Concepts.

Meniscal root repair and joint preservation surgeries have gained increased interest in the last decade, from a better interpretation of the role of meniscal functions, from the biomechanical studies. Several published results from both biomechanical and clinical studies has proven the effectiveness of meniscal root repairs and has led to a unanimous international consensus for the need for root repair surgery. Meniscal repair by suture pull-out technique is widely followed around the world and leads to adequate healing and good clinical outcome. There are auxiliary procedures like centralization sutures (to reduce the meniscal extrusion), high tibial osteotomy, cartilage repair procedures, meniscal root reconstruction and ligament reconstructions are performed along with meniscal root repair, especially in the younger patients and recently sub-chondroplasty for the bone marrow lesions (BMLs) are also executed. This review article discusses the anatomy, types of root tears, evaluation, treatment, outcomes of root repair, and the need for additional procedures, which are imperative for joint preservation and restoration of the biomechanics of the knee.

Arthroscopic reduction and internal fixation (ARIF) versus open reduction internal fixation (ORIF) to elucidate the difference for tibial side PCL avulsion fixation: a randomized controlled trial (RCT).

PURPOSE: To compare the clinical, radiological outcomes, economic and technical differences for ORIF by cancellous screw fixation versus ARIF by double-tunnel suture fixation for displaced tibial-side PCL avulsion fractures. METHODS: Forty patients with displaced tibial-sided PCL avulsions were operated upon after randomizing them into two groups (20 patients each in the open and arthroscopic group) and followed up prospectively. Assessment included duration of surgery, cost involved, pre- and post-operative functional scores, radiological assessment of union, and posterior laxity using stress radiography and complications. RESULTS: The mean follow-up period was 33 months (27-42) (open group) and 30 months (26-44) (arthroscopic group). The duration of surgery was significantly larger in the arthroscopic group (47.8 ± 17.9 min) as compared to the open group (33.4 ± 10.1 min). The costs involved were significantly higher in the arthroscopic group (p- 0.01). At final follow-up, knee function in the form of IKDC (International Knee Documentation Committee) evaluation (89.9 ± 4.8-open and 89.3 ± 5.9-arthroscopic) and Lysholm scores (94.2 ± 4.1-open and 94.6 ± 4.1-arthroscopic) had improved significantly with the difference (n.s.) between the two groups. The mean posterior tibial displacement was 5.7 ± 1.8 mm in the open group and 6.3 ± 3.1 mm in the arthroscopic group which was (n.s.). There were two non-unions and one popliteal artery injury in the arthroscopic group. CONCLUSION: Both ARIF and ORIF for PCL avulsion fractures yield good clinical and radiological outcomes. However, ORIF was better than ARIF in terms of cost, duration of surgery, and complications like non-union and iatrogenic vascular injury. LEVEL OF EVIDENCE: II.

Do coracohumeral interval and glenoid version play a role in subscapularis tears?

PURPOSE: To study the effect of the coracohumeral interval and orientation of the glenoid for causation of subscapularis tears and literature review for the need of coracoplasty. METHODS: This is a retrospective cohort study of patients who underwent arthroscopic shoulder surgery from January 2013 to December 2017. The coracohumeral interval and orientation of the glenoid in patients with arthroscopically diagnosed subscapularis tears (group A, n = 40) were compared with 2 control groups (group B, n = 38 [intact subscapularis with supraspinatus and infraspinatus cuff tears] and group C, n = 39 [intact rotator cuff]). Group A1 (n = 23) consisted of the isolated subscapularis and combined subscapularis + supraspinatus tears, and group A2 (n = 17) all the 3 rotator cuff tears. The measurements were made on preoperative axial magnetic resonance imaging. Statistical analysis was performed to compare the groups. RESULTS: The mean coracohumeral interval was 8.81 ± 2.69 mm in group A and 10.62 ± 2.21 and 10.39 ± 2.59 mm in control groups B and C, respectively; this difference was statistically significant (P = .002 and .01, respectively). The mean glenoid version in patients with subscapularis tears was -3.7°, whereas the mean version in patients with intact cuff was -3.4°, and this difference was not statistically significant (P = .74). The mean glenoid version was -4.69° ± 4.22° in group A1 and -3.28° ± 4.04° in group B, with no statistically significant difference (P = .07). CONCLUSION: The coracohumeral interval was significantly decreased in patients with subscapularis tears. The glenoid was retroverted in the subscapularis group but was not statistically significant.

Does change in occupancy ratio and fatty infiltration of the supraspinatus influence functional outcome after single-row rotator cuff repair? A magnetic resonance imaging-based study.

INTRODUCTION: The purpose of this study was to analyze the correlation of occupancy ratio (OR) and fatty infiltration (FI) to functional outcome and retear rate following rotator cuff repair by single-row technique. MATERIAL AND METHODS: Retrospectively, all the patients (n = 100) with rotator cuff tear were evaluated preoperatively and postoperatively with functional scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], University of California-Los Angeles [UCLA] shoulder score, Constant score) and magnetic resonance imaging (MRI) for OR and FI. Two observers studied the MRI data separately. Statistical analysis was done using SPSS (version 16), paired t test, Pearson correlation, and intraclass correlation coefficients. RESULTS: The mean (± standard deviation) follow-up was 16.24 ± 6.39 months, and the mean age was 56.18 ± 7.5 years. There was a significant increase in muscle atrophy (decreased OR) and FI (P < .01). The mean preoperative and postoperative ORs were 0.57 and 0.51, respectively. However, the mean functional scores improved significantly for ASES (55.78 to 82.09), UCLA (19.44 to 28.47), and Constant score (49.73 to 75.07) (P < .001). There was no significant difference in functional outcome among the different stages of FI (ASES P = .341, UCLA P = .839, Constant P = .376). Seven patients had asymptomatic retear during follow-up, of which 2 patients had grade 3, 4 patients had grade 2, and 1 patient had grade 1 FI, preoperatively. CONCLUSION: Muscle atrophy and FI are irreversible phenomena and continue even after successful repair; however, they do not have a significant influence on the functional outcome at short-term follow-up after cuff repair. Repairing cuff with higher grades of FI can be performed as they achieve significantly improved functional outcomes.

Prediction of recurrence based on the patellofemoral morphological profile and demographic factors in first-time and recurrent dislocators.

INTRODUCTION: Prediction of recurrence in first-time patellar dislocation is an unsolved mystery. The purpose of our study is to compare patellar instability patients and normal control groups with anatomical risk factors and validation of newer parameters patello-trochlear index (PTI) and tibial tuberosity-posterior cruciate ligament (TT-PCL) and also to find the significant risk factors that help to predict the recurrence of dislocation in first-time dislocators. METHODS: This is a comparison study between 50 normal individuals as a control population (group-1) and 94 patients with patellar instability done between 2013 and 2017. Further, 94 patients (group-2) were divided into first-time dislocators (group-2A) and recurrent dislocators (group-2B) which include 39 and 55 patients, respectively. Demographic factors like age, sex, the age of the first dislocation, mechanism of injury, and laterality and MRI risk factors like trochlear dysplasia, patellar height, patellar malalignment, and lateralization of tibial tuberosity were statistically analyzed. RESULTS: All parameters used to measure each MRI factors showed significant difference with p value < 0.0001 between group 1 and group 2 except PTI (0.035) and TT-PCL (0.036). While comparing demographic factors between first-time dislocators and recurrent dislocator groups, patients with first-time dislocation < 16 years of age (OR-3.6) and bilateral involvement are associated with recurrence and among MRI factors, trochlear dysplasia (odds ratio OR-12), patellar tilt (OR-0.2), and patella alta (OR-4.9) were known to be associated with higher chance of recurrence. CONCLUSION: There is a significant difference in anatomic risk factors between normal and patellar instability knees. PTI and TT-PCL are less significant than the previous parameters. Age < 16 years, the presence of trochlear dysplasia, patella alta, and bilateral involvement have a significant role as prediction factors in a recurrent dislocation in both adolescents and adults.