Arthroplasty at Very High Altitude with Restricted Resources: Our Experience and Review of Literature.

Introduction: Patients living in high altitudes are often deprived of total knee arthroplasty (TKA) due to logistic reasons, economic, and social challenges in performing surgical procedures for management of knee pain. Surgical procedures in high-altitude dwellers have associated risk of deep venous thrombosis/pulmonary embolism (DVT/PE). In patients undergoing these procedures at lower altitudes, return to high altitudes can cause high-altitude pulmonary edema (HAPE). We share our experience of performing TKA in high-altitude dwellers by setting up a surgical camp at 11,000 feet. Methods: A retrospective assessment of patients undergoing total knee arthroplasty at a camp set up at 11,000 feet between 2014 and 2020 was undertaken. Follow-up data of patients which included clinical assessment by the Knee Society Score (KSS) and complications like DVT, infection, residual deformity, etc. were included in the study. Radiographic evaluation to look for evidence of implant loosening was also inculcated. Results: 132 patients (202 knee joints in 50 male and 82 female patients) underwent TKA during annual camps. The average follow-up of patients was 60 months. Mean pre-operative KSS was 38, which was increased to 83 at 1-year follow-up post-surgery. There was no evidence of DVT or superficial or deep infection in any patient in the post-operative period. Conclusion: With this study, we want to highlight that total knee arthroplasty can be safely performed at high altitudes and remote areas with limited health facilities. We believe it is a safer and more convenient prospect for the residents of high-altitude regions. Level of evidence: III.

Does One Size Really Fit All? Morphometric Analysis of Distal Femur and Proximal Tibia in an Ethnic Indian Population and Correlation to the Sizing of Existing Total Knee Arthroplasty Implants.

BACKGROUND: Total knee arthroplasty (TKA) has been proven to be a highly efficacious procedure for patients with end-stage osteoarthritis who have persistent symptoms not managed by conservative treatment. A large percentage of standard commercially available total knee arthroplasty (TKA) implants are imported and designed based on morphometric data of Western populations, which are known to have a larger build compared to their Asian counterparts. Hence, these prostheses may sometimes not be the best fit for Indian patients. We conducted this study to examine the anthropometry of osteoarthritic knees of Indian patients, analyze anatomical differences between males and females, and compare these measurements with commercially available five TKA implants. METHODS: Morphometric data were collected from 150 Indian patients with osteoarthritis of the knee using computed tomography (CT) scans. The mediolateral (ML) and anteroposterior (AP) dimensions of the distal femur and proximal tibia were measured, and aspect ratios (ML/AP) were calculated. These measurements were correlated with current commercially available implant sizes. RESULTS: We examined CT scans of 100 female and 50 male patients' knees with a combined average age of 58.2 ± 7.5 years. The mean mediolateral and anteroposterior dimensions of the distal femur for Indian knees were 74.5 ± 5.8 mm and 58.0 ± 4.2 mm, respectively, whereas for the proximal tibia, 69.1 ± 5.5 mm and 43.8 ± 3.6, respectively. The mean aspect ratio for the femur was 129.0 ± 6.0 and for the tibia was 158.1 ± 9.1. Male dimensions were found to be greater than female dimensions in all measured aspects of the distal femur and proximal tibia for the Indian population. However, the aspect ratio of the tibia was not found to vary with gender. When compared with the dimensions of other ethnic groups, the size of Indian knees was found to be smaller than Caucasians. CONCLUSIONS: There is a mismatch between the anatomy of Indian knees and currently available TKA implants, and these implants may have drawbacks when implanted in Indian patients. The obtained anthropometric data may provide useful directions for designing TKA implants of more suitable sizes and aspect ratios for Indian patients.

Functional characterisation of ADP ribosylation factor-like protein 15 in rheumatoid arthritis synovial fibroblasts.

OBJECTIVES: ARL15 is a novel susceptibility gene identified in a recent GWAS in a north Indian rheumatoid arthritis (RA) cohort. However, the role of ARL15 or ARF family genes in RA aetiology remains unknown. Therefore, we aimed to i) establish the expression of ARL15 in rheumatoid arthritis synovial fibroblasts (RASF) and ii) its functional characterisation by assessing its effects on major inflammatory cytokines and interacting partners using a knockdown approach. METHODS: RASF were cultured from synovial tissue obtained from RA patients (n=5) and osteoarthritis (OA) patients (n=3) serving as controls. Expression of ARL15, ARF1 and ARF6 in RASF was checked by semi-quantitative PCR and western blots; and altered expression of ARL15, if any, by induction of RASF with TNF using real-time PCR. The effect of ARL15 on the expression of adiponectin, adiponectin receptor I, IL6 and GAPDH and on cell mobility by invasion and migration assays were assessed by siRNA mediated gene knockdown. RESULTS: Expression of ARL15, ARF1 and ARF6 was confirmed in RASF and OASF samples but ARL15 expression remained unaltered on TNF induction. Notably, ARL15 knockdown resulted in downregulation of IL6 and GAPDH, upregulation of adiponectin and adiponectin receptor I genes; and significant reduction in migration and invasion of RASF. Genemania showed significant interactions of ARL15 with genes responsible for insulin resistance and phospholipase D. CONCLUSIONS: This first report on ARL15 expression in RASF and its likely role in inflammation and metabolic syndromes through a TNF independent pathway, encourages hypothesis-free studies to identify additional pathways underlying RA disease biology.

Fracture of the polyethylene tibial post in a posterior stabilized knee prosthesis: A case report and review of literature.

We report a case of fracture of tibial polyethylene post fracture from base in a 56 year old lady 10 years from posterior stabilized total knee arthroplasty following trivial trauma. There have been signs of wear at the base especially anteriorly. After revision of tibial polyethylene component patient developed complete relief of symptom.

Evaluation of pain in bilateral total knee replacement with and without tourniquet; a prospective randomized control trial.

AIM: Thigh pain following tourniquet application is a common complaint in early post operative period following total knee arthroplasty. METHOD: Post operative Thigh pain was evaluated in 30 consecutive simultaneous bilateral total knee arthroplasty patients between July 2013 and January 2014. Patient thigh pain was evaluated with the VAS score. The scale was applied on first, second, third day & second and six weeks after surgery. RESULT: There were statistically significant difference in VAS score in non-tourniquet group on first, second, third post operative day. We did not find statistically significant difference at Second and Six weeks post operatively. CONCLUSION: This Randomized trial demonstrates that non-tourniquet use in TKA has less early postoperative pain and leads to better recovery.

Direct Repair without Augmentation of Patellar Tendon Avulsion following TKA.

Complications involving the extensor mechanism after TKA are potentially disastrous. We are reporting a case of patellar tendon rupture from tibial tuberosity following total knee arthroplasty. We managed it by direct repair with fiberwire using Krackow suture technique without augmentation. Our long term result has been very encouraging. Our method is a safe and better method of management of patellar tendon avulsion following TKA when it happens without any tissue loss.

Comparison of conventional infrainguinal versus modified proximal suprainguinal approach of Fascia Iliaca Compartment Block for postoperative analgesia in Total Hip Arthroplasty. A prospective randomized study.

Fascia Iliaca Compartment Block (FICB) has been widely used as a postoperative analgesic adjunct to opioids for total hip arthroplasty (THA), either by the conventional infrainguinal approach or the modified proximal suprainguinal approach irrespective of any specific advantage of one over the other. This study was conducted to compare the analgesic efficacy of the two techniques of FICB for postoperative analgesia. The 40 patients scheduled for THA were recruited for Intervention (s) and randomized to receive FICB either by suprainguinal approach (group S) or infrainguinal approach (group I) for postoperative analgesia with 40 ml of 0.2% bupivacaine, in addition to postoperative patient controlled analgesia (PCA) with morphine. Visual analogue scale (VAS) and PCA morphine consumption was used to assess the postoperative pain at 3, 6, 12 and 24 hours. The primary outcome was cumulative PCA morphine consumption in 24 hours. The pain intensity as measured by VAS scores showed significant reduction of intensity at 6 hours post block in group S as compared to group I (median [IQR]; 2[0-3]; 3[2.25-3]; p = 0.001) but, there was no significant difference in VAS at 12 and 24 hours. Postoperatively, there was significant difference in time to first PCA morphine demand (356.28 ± 33.32 vs 291.48 ± 37.17, p = < 0.001, respectively) in-group S vs. group I. The postoperative morphine consumption was also significantly less in group S compared to group I at 6, 12 and 24 hours and the cumulative morphine consumption in 24 hours (6.95 ± 2.14 vs 10.50 ± 2.24, p = < 0.001 respectively) was also less. In conclusion, in THA, suprainguinal approach of FICB has a superior postoperative analgesic efficacy compared to infrainguinal approach of FICB along with significantly less morphine consumption in first 24 hours.

How to interpret postoperative X-rays after total knee arthroplasty.

Today, total knee arthroplasty (TKA) is one the most commonly performed surgeries worldwide. The purpose of this article is to review the appearance of normal post-TKA roentgenographs and describe the correct sequence for their interpretation. It is unwise to depend solely on patients' symptoms when diagnosing TKA complications because serial radiographs can foresee failures well before they manifest clinically. Ideal post-TKA radiographs comprise whole lower extremity anteroposterior and lateral views taken under weight bearing conditions along with a skyline view of the patellofemoral joint. Among other things, weight bearing exposes the true alignment, ligamentous laxity and polyethylene wear. On the basis of follow-up of our TKA cases, we have drawn up a protocol for assessing postoperative X-ray films after TKAs. Following the proposed sequence, surgeon can easily decide how to proceed with follow-up and foresee complications. Careful interpretation of postoperative radiographs after TKA is essential to careful monitoring of patients and implant survival.

Evaluation of proximal femoral locking plate in unstable extracapsular proximal femoral fractures: Surgical technique & mid term follow up results.

BACKGROUND: Stable trochanteric femur fractures can be treated successfully with conventional implants such as sliding hip screw, cephalomedullary nails, angular blade plates. However comminuted and unstable inter or subtrochanteric fractures with or without osteoporosis are challenging & prone to complications. The PF-LCP is a new implant that allows angular stability by creating fixed angle block for treatment of complex, comminuted proximal femoral fractures. METHOD: We reviewed 30 patients with unstable inter or subtrochanteric fractures, which were stabilized with PF-LCP. Mean age of patient was 65 years, and average operative time was 80 min. Patients were followed up for a period of 3 years (June 2010-June 2013). Patients were examined regularly at 3 weekly interval for signs of union (radiological & clinical), varus collapse (neck-shaft angle), limb shortening, and hardware failure. RESULT: All patients showed signs of union at an average of 9 weeks (8-10 weeks), with minimum varus collapse (<10°), & no limb shortening and hardware failure. Results were analysed using IOWA (Larson) hip scoring. Average IOWA hip score was 77.5. CONCLUSION: PF-LCP represents a feasible alternative for treatment of unstable inter- or subtrochanteric fractures.

Role of locking plates in treatment of difficult ununited fractures: a clinical study.

OBJECTIVE: To present our experience in treatment of difficult ununited long bone fractures with locking plate. METHODS: Retrospective evaluation of locking plate fixation in 10 difficult nonunions of long bone fractures was done. Fixation was done with locking plate for femoral shaft fracture (3 patients), supracondylar fracture of femur (gap nonunion), fracture of clavicle, fracture of both forearm bones (radius and ulna) fracture of ulna, fracture of shaft of humerus, fracture of tibial diaphysis and supracondylar fracture of humerus (one patient each). Five fractures had more than one previous failed internal fixation. One patient had infected nonunion which was managed by debridement with cast immobilization followed by fixation with locking plate at six weeks. Seven fractures were atrophic, two were oligotrophic, and one was hypertrophic. Fibular autograft was used in 2 cases and iliac crest cancellous bone graft used in all the patients. RESULTS: Minimum follow-up was 6 months (range, 6 months to 2.5 years). Average time for union was 3.4 months (range 2.5 to 6 months). None of the patients had plate-related complications or postoperative wound infections. CONCLUSION: Along with achieving stability with locking compression plate, meticulous soft tissue dissection, acceptable reduction, good fixation technique and bone grafting can help achieve union in difficult nonunion cases. Though locking plate does not by itself ensure bony union, we have found it to be another useful addition to our armamentarium for treating difficult fracture nonunions.

Quinalphos induced oxidative stress and histoarcheitectural alterations in adult male albino rats.

Quinalphos is a synthetic organophosphate used as a broad spectrum insecticide and acaricide. The present study investigates the effect of three sub-lethal doses (0.52, 1.04, 2.6 mg/kg b.wt) of quinalphos for variable durations (15, 30 and 90 days) on oxidative stress and histopathological changes in adult male rats. Quinalphos treatment for 15 and 30 days resulted in a dose dependent significant increase in malondialdehyde (MDA) levels and glutathione-S-transferase (GST) activity together with a concurrent decrease in ferric reducing ability of plasma (FRAP) and glutathione (GSH) content. Quinalphos treatment for 90 days also induced a significant increase in MDA levels and GST activity but the effect was not dose-dependent. Histopathological examination of liver revealed architectural disarray and dilatation of sinusoids, focal fatty changes, accumulation of eosinophils and single cell necrosis with increasing doses. However, spleen and kidney did not show any histological changes. Administration of quinalphos resulted in oxidative stress and free radical induced injury as evidenced by increased lipid peroxidation, decreased FRAP and histopathological changes in liver.