Is There a Need for an Exogenous Activator Along with PRP for Early Knee Osteoarthritis? A Triple-Blinded Randomized Control Trial.

Background: In addition to other variables associated with PRP injections for Knee Osteoarthritis (OA), some confusion exists about the role of exogenous activators. The current study looks at matched groups getting PRP injections with or without activator (Calcium gluconate) in early knee OA patients. Methods: Patients of early OA knee meeting inclusion criteria were randomly divided into 2 groups; Group A (43 patients) received 8 ml PRP injection alone, and Group B (48 patients) received 8 ml PRP along with 2 ml Calcium gluconate as activator. The patients were evaluated at baseline, 6 weeks, 3 months and 6 months for WOMAC Pain and Total WOMAC scores; secondary variables assessed were VAS score and patient satisfaction. Results: The baseline characteristics of both groups were comparable. Leucocyte-depleted PRP with 5 times concentration and average absolute platelet numbers of 7.144 billion per knee was injected. Mean Pain WOMAC scores decreased in both groups from baseline (group A-8.68, group B-9.09) to final follow-up (group A-4.67, group B-5.11). Similarly, Mean Total WOMAC scores decreased from baseline (group A-37.81, group B-37.41) to (group A-21, group B-21.36) at the final follow-up in both groups. There was no significant difference between both groups, and both showed similar trends. Similar findings were noted for VAS scores. Patient satisfaction was also not different (group A, 90.69%, group B, 89.58%) at the end of 6 months. Conclusion: Our study concluded doubtful role of adding exogenous activator to PRP preparation. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-024-01159-7.

Chondroprotective Effects of a Single PRP Injection in a Spontaneous Osteoarthritis Model of Dunkin Hartley Guinea Pig: An Immunohistochemical Analysis.

Purpose of the Study: The evaluation of anti-apoptotic and chondroprotective properties of a single injection of PRP using immunohistochemistry (IHC). Methods: This was a placebo-controlled blinded experimental study. Ten healthy Dunkin Hartley guinea pigs were selected. One knee of each animal was injected with a single injection of PRP (Group A); the contralateral knee acted as a control and was injected with a single injection of normal saline (Group B). These groups were further divided into A3 and B3 based on the timeline of animal sacrifice (3 months) and A6 and B6 (6 months). The formalin-preserved articular cartilage blocks were subjected to IHC to stain Aggrecan, Caspase-3, and Collagen-2. Results: The mean IHC score was significantly low for Caspase-3 (p-0.029) in intervention group (A3) in comparison to placebo control group (B3) pointing towards decreased apoptosis. The mean IHC values were significantly higher for Collagen II (p-0.011) for intervention group (A6) in contrast to control group (B6); values were also significantly low for Caspase-3 (p-0.029) in A6 as compared to B6. The mean Caspase-3 values were significantly higher in A6 as compared to A3 (p-0.029). Conclusion: The impact of a solitary injection of PRP on upregulation of anabolic pathways inside cartilage is relatively slower as compared to its effect on downregulation of apoptotic pathways. Even a single PRP injection holds the potential to change cartilage microenvironment, but the effects are not long lasting.

Minimally Invasive Osteotomy for Correction of Post-Traumatic Tibia Internal Rotation Deformity: A Case Report.

Introduction: Intramedullary nailing is a commonly performed surgery for tibia diaphysis fractures. However, in selected cases, this procedure can get complicated with rotational malalignment if not checked carefully intra-operatively. Case Report: A 29 year-old male sustained polytrauma and was treated with intramedullary nailing for bilateral femur and right-side tibia fractures. Postoperatively, the patient noticed extreme in-toeing suggesting an internal rotation deformity, which caused great difficulty in walking. The patient was planned for a revision surgery to correct the internal rotation deformity, 6 months after the index surgery. A minimally invasive metaphyseal osteotomy was performed, away from his fracture site by drilling multiple holes. The distal locking bolts of the interlocking nail were removed, and two K wires used to achieve the desired correction angle. After rotating the distal fragment, locking bolts were reinserted in new holes. We kept the patient on our regular follow-up till he achieved sound union at the osteotomy site, after which we allowed him unrestricted activities. Conclusion: The presence of an intramedullary nail can hence help the surgeon in correcting such isolated rotational deformities without getting into the hassle of implant removal to achieve the same.

Debate on direct-anterior vs posterior approach for hip hemiarthroplasty: The authors' insights.

We read and discussed the study entitled "Complication rates after direct anterior vs posterior approach for Hip Hemiarthroplasty in elderly individuals with femoral neck fractures" with great interest. The authors have done justice to the topic of comparison of anterior and posterior surgical approaches for bipolar hemiarthroplasty which has been an everlasting debate in the existing literature. However, there are certain aspects of this study that need clarification from the authors.

Evaluation of the Stability of Internal Fixation Constructs in a Low Distal Tibia Extra-articular Cadaveric Fracture Model: A Comparative Biomechanical Study.

Introduction Despite the recent advances in implant design, the choice of an internal fixation modality for extra-articular distal tibia fractures remains controversial, and there is sparse literature comparing the stability of intramedullary nails and locked plates for such fractures. Hence, we conducted a biomechanical study on an AO type 43A3 tibia fracture cadaveric model stabilized by four different constructs, viz., intramedullary (IM) interlocking nail, anteromedial plate, anterolateral plate, and posterior plate. An AO type 43A3 fracture is defined as an extra-articular fracture of the distal tibia with metaphyseal comminution. Methods A biomechanical comparative study on formalin-preserved human cadaveric tibiae was undertaken; a total of four groups were tested, with eight bones in each group. Out of the 32 cadaveric tibiae, 19 bones belonged to male cadavers, and 13 bones belonged to female cadavers. All bones were dissected from age-appropriate cadavers and fixed with an implant, followed by the creation of a 1 cm osteotomy to simulate an AO type 43A3 fracture. All fixation constructs were subjected to three-point bending tests in the anteroposterior (AP) and mediolateral (ML) planes. Three parameters, viz., bending stiffness, peak fracture gap angle, and neutral zone, were evaluated on the load-displacement curves. A fixation construct was deemed biomechanically stable if it had a high bending stiffness, a low neutral zone (inherent toggle in the construct by its weight), and a low peak fracture gap angle. Results Out of the four implants tested, locked IM nails exhibited the maximum biomechanical stability in terms of higher bending stiffness, smaller peak fracture gap angle, and smaller neutral zones. The IM nail exhibited the highest bending stiffness in the AP plane, and the anterolateral plate had the lowest bending stiffness, and the difference was statistically significant (p= 0.032). In the AP plane, the anterolateral plate exhibited a bending stiffness of 1.51 ± 0.69 Nm/degree, whereas the intramedullary nail exhibited a bending stiffness of 2.34 ± 0.81 Nm/degree, and the posterior locked plate had a bending stiffness of 1.57 ± 0.44 Nm/degree. In the ML plane, the anterolateral plate exhibited the highest neutral zone as compared to the intramedullary nail, which had the lowest neutral zone, and the difference was statistically significant (p = 0.019). The intramedullary nail exhibited the lowest neutral zone of 0.46 ± 0.31 degrees, whereas the posterior locked plate exhibited a neutral zone of 0.78 ± 0.43 degrees in the ML plane. The anterolateral plate exhibited a neutral zone of 1.43 ± 1.00 (expressed as mean ± SD) degrees in the mediolateral plane. Conclusion Our biomechanical study supports the recommendations of using a locked intramedullary nail for AO type 43A3 fractures. We concluded that the anterolateral plate construct exhibited the least biomechanical stability, in terms of lower AP bending stiffness and higher neutral zone. If the surgeon must choose a locked plating technique for any reason, the anterolateral locking plate should be avoided. If plating is at all required, we can recommend both anteromedial and posterior locked plating as biomechanically sound options.

Corrective Osteotomy and Ligamentous Reconstruction in a Neglected Elbow Dislocation with Radial Neck Malunion: A Case Report.

CASE: Neglected elbow dislocation and radial neck malunion frequently result in chronic pain, instability, and early arthrosis. These complications are best prevented by early treatment with open reduction, corrective osteotomy, and ligament reconstruction, followed by early supervised physiotherapy. We present a peculiar case with neglected complex elbow dislocation and radial head malunion. In this case, we performed an open reduction of the elbow joint and radial neck corrective osteotomy, medial collateral ligament, annular ligament reconstruction, and lateral collateral ligament repair. CONCLUSION: Neglected complex elbow dislocations require reconstruction of both ligamentous and osseous structures to achieve a good functional outcome.

Comparison of Conventional Dose Versus Superdose Platelet-Rich Plasma for Knee Osteoarthritis: A Prospective, Triple-Blind, Randomized Clinical Trial.

Background: Confusion persists regarding the ideal dosage of platelet-rich plasma (PRP) injection for knee osteoarthritis (OA). Purpose/Hypothesis: The purpose of the study was to compare the efficacy of 2 different single-injection PRP dosages in patients with early knee OA-a conventional 4 mL dose and a superdose of 8 mL. It was hypothesized that 8 mL of PRP would be superior to 4 mL of PRP in this patient population. Study Design: Randomized clinical trial; Level of evidence, 1. Methods: Patients with early knee OA (Kellgren-Lawrence grades 1 and 2) who met the inclusion criteria were randomly divided into 2 groups: Group A (n = 50 knees) received a 4-mL PRP injection, and group B (n = 49 knees) received an 8-mL PRP injection, both prepared using the same procedure. Patients were evaluated at the baseline, 6 weeks, 3 months, and 6 months using the Western Ontario and McMaster Universities Arthritis Index (WOMAC), the WOMAC-Pain subscale, the visual analog scale for pain, the Knee injury and Osteoarthritis Outcome Score, and patient satisfaction, and results were compared between the groups. Results: The baseline characteristics of the 2 groups were comparable (group A: mean age, 51.96 ± 6.93 years; group B: mean age, 49.12 ± 9.8 3 years). Leucocyte-depleted PRP with 3.5 times concentration (final product platelet concentration, 706.74 × 103-µL) was injected. The mean absolute platelet count injected was 2.82 ± 0.0012 billion in group A and 5.65 ± 0.0022 billion in group B. All patient-reported outcome scores improved significantly in both groups from the baseline to the final follow-up (P < .001), with overall trends and results significantly better in group B than in group A (P < .001). Patient satisfaction at the 6-month follow-up was also better in group B (96%) compared with group A (68%). Short (2 to 7 days) self-limiting complications, such as pain and stiffness, occurred more often in group B (P < .001). Conclusion: Patients with early knee OA had significantly better improvement in pain and function when treated with an 8-mL injection of PRP compared with a 4-mL injection of PRP. The larger dose of PRP had approximately twice the number of platelets. Registration: CTRI/2020/02/023403 (Clinical Trials Registry-India identifier).

A Cost-Effective Novel Surgical Technique of Core Decompression with Bone Marrow Aspiration Concentrate: A Preliminary Cadaveric Study.

Introduction: Core decompression supplemented by stem cell incorporation is an upcoming field of research in avascular necrosis of the femoral head. Plugging the canal to avoid loss of the concentrate injected has been recognized as a crucial step to improve the efficacy of the procedure. We describe a new surgical technique that results in native bone plug formation and eliminates the need for any additional blocker. Methodology: This pilot study was performed on 4 cadaveric proximal femurs. The standard technique was used for core decompression and bone marrow aspirate concentrate (BMAC) injection. Additionally, two more tracts were drilled, superolateral, and inferomedial to the primary tract. Results: No leakage of the radiopaque dye was observed from the entry point of the primary tract, ensuring its complete blockage in all 4 cadaveric proximal femurs. This was confirmed by sectioning the femur specimens which manifested bone plug formation at the confluence of the three tracts. Conclusion: Our technique is a unique and economical method of preventing leakage of BMAC through the entry point in the proximal femoral metaphysis. This may not only benefit patients but can also provide the groundwork for further research in this field.

Lupus miliaris disseminatus faciei: a distinctive facial granulomatous eruption.

Facial granulomatous papules are important to recognise, as some of them are associated with significant systemic association, particularly sarcoidosis and certain infectious conditions. Lupus miliaris disseminatus faciei (LMDF) is a benign granulomatous disorder of unknown aetiology characterised by symmetrical, monomorphic, reddish-brown papules on the face. It is not associated with any underlying systemic involvement. We report a case of LMDF in a middle-aged man who presented to us with multiple asymptomatic and monomorphic reddish papules on the face for 3 months. Skin biopsy showed well-formed perifollicular epithelioid cell granulomas with focus of necrosis suggestive of LMDF. The lesions significantly responded to oral steroids.