Identification of novel inhibitor phytoconstituents for Influenza A H3N2: an in silico approach.

Influenza A virus subtype H3N2 is a highly infectious respiratory virus that is responsible for global seasonal flu epidemics. The current study was designed to investigate the antiviral activity of 150 phytocompounds of North Western Himalayas medicinal plants by molecular docking. Two target proteins of hemagglutinin of influenza virus A (PDB ID 4WE8) and Influenza virus H3N2 nucleoprotein - R416A mutant (PDB ID 7NT8) are selected for this study. Molecular docking was done by AutoDock vina tool, toxicity and drug-likeness prediction was done by protox II and Moleinspiration. MD simulation of best protein-ligand complexes was done by using Gromacs, version 2021.5. Molecular docking and toxicity data revealed that clicoemodin and rumexocide showed the best binding with both target proteins 4WEB & 7NT8. Clicoemodin showed the -7.5 KJ/mol binding energy with 4WE8 and 7NT8. Similarly, rumexoside showed the -7.6 KJ/mol binding energy with 4WE8 and -7.6 KJ/mol with 7NT8. Furthermore, Molecular dynamic simulation and MMPBSA binding free energy validated the stability of protein-ligand complexes. The current study suggested that clicoemodin and rumexocide are the promising inhibitors of H3N2 proteins hemagglutinin of influenza virus A and Influenza virus H3N2 nucleoprotein - R416A mutant, though there is further in vitro and in vivo validation is required.Communicated by Ramaswamy H. Sarma.

Comparison of "ligamentization" process between preserved insertion hamstring tendon autograft and bone-patellar tendon-bone autograft.

BACKGROUND: Ligamentization is a complex process and effect of preservation of hamstring tendon graft insertion on this process is not well studied. Present study was conducted to analyze and compare the ligamentization of semitendinosus gracilis graft with preserved tibial insertion (STGPI) and bone-patellar tendon-bone (BPTB) autografts. METHODS: A total of 50 sportspeople who underwent ACL reconstruction using either BPTB (group A; n = 25) or STGPI (group B; n = 25) autografts were included in the study. Contrast enhanced MRI was done at 8 months and 14 months post-ACL reconstruction to evaluate the ligamentization using Signal noise quotient (SNQ), graft intensity and enhancement index. Clinical outcomes (Lysholm score) and knee laxity were also assessed at 8 months and 14 months. RESULTS: 18/23 (78%) patients in group A and 14/23 (61%) patients in group B had hyperintense graft signal at 8 months (n.s.) and at 14 months, 1/23 patients in group A and none of the patients in group B had hyperintense graft. SNQ at 8 months was 3.6 ± 2 and 3.7 ± 2 in group A and B respectively (n.s.) and at 14 months, SNQ was 2.5 ± 1.5 in group A and 2.4 ± 1.3 in group B (n.s.). Enhancement index at 8 months was 1.5 ± 0.3 and 1.2 ± 0.3 in group A and B respectively (p = 0.0001). Enhancement index at 14 months was 1.21 ± 0.2 in group A and 1.07 ± 0.2 in group B (p = 0.003). Functional outcomes and knee laxity were comparable in both the groups at 8 and 14 months (n.s.). CONCLUSION: Both the grafts i.e. BPTB and STGPI are similar in terms of rate and extent of ligamentization. Clinical outcomes and knee laxity are also comparable between two grafts.

A comprehensive insight on the challenges for COVID-19 vaccine: A lesson learnt from other viral vaccines.

The aim of this study is to comprehensively analyze previous viral vaccine programs and identify potential challenges and effective measures for the COVID-19 vaccine program. Previous viral vaccine programs, such as those for HIV, Zika, Influenza, Ebola, Dengue, SARS, and MERS, were evaluated. Paramount challenges were identified, including quasi-species, cross-reactivity, duration of immunity, revaccination, mutation, immunosenescence, and adverse events related to viral vaccines. Although a large population has been vaccinated, mutations in SARS-CoV-2 and adverse events related to vaccines pose significant challenges. Previous vaccine programs have taught us that predicting the final outcome of the current vaccine program for COVID-19 cannot be determined at a given state. Long-term follow-up studies are essential. Validated preclinical studies, long-term follow-up studies, alternative therapeutic approaches, and alternative vaccines are necessary.

Concepts in wound irrigation of open fractures: 'Where we came from, and where are we now?

Wound irrigation is described as the flow of a solution through an exposed fracture surface to reduce the microbial colonization, to remove apparent foreign particles and wound exudates. . While recent literature and various in-vitro and in-vivo trials have cleared some clouds of doubt from the mind, it still remains a topic of debate. Normal saline remains the standard irrigation solution as it is non tissue toxic and has the same tonicity as body fluids. The quantity and duration of washing though is not standardized and is the surgeon's choice. This adds to the dilemma in the minds of the surgeon, with the timing of the debridement and the duration of wound irrigation depending on the surgeon's discretion. Future studies should aim to regulate the duration of the wound irrigation besides guiding about the ideal fluid volume to be used for the irrigation. Further, secondary end-points like the duration of hospital stay, rate of infections and use of hospital resources, should be computed to know about the adequacy of the wound debridement and irrigation. Antimicrobial solutions can kill microorganisms in the wound but are toxic to the host tissues as well, which limits their use. In addition, pulsatile (high pressure) lavage has not been seen to increase overall effectiveness. Recent research trials have found cumulative use of innovative solutions like phenols and EDTA along with enzymes to be encouraging though large randomized controlled trials are lacking.

High Prevalence of Vitamin D Deficiency among North Indian Athletes.

BACKGROUND: Vitamin D deficiency is high in athletes and has an impact on athletes' performance. INTRODUCTION: Assessment of serum Vitamin D levels in healthy North Indian sportspersons and its correlation with serum parathyroid hormone (PTH) levels and bone mineral density (BMD). MATERIALS AND METHODS: Three-hundred and sixty-nine healthy athletes' aged 18-45 years were enrolled. Depending upon Vitamin D levels athletes were categorized into three groups: deficient (<20 ng/ml), insufficient (20-30 ng/ml), and sufficient (>30 ng/ml). BMD and serum PTH levels were assessed in all athletes and correlation was seen with Vitamin D levels. RESULTS: Two-hundred and fifty-eight (69.9%) athletes were Vitamin D deficient, 51/369 (13.8%) were Vitamin D insufficient, and 60/369 (16.3%) athletes were Vitamin D sufficient. There was a direct correlation between low serum Vitamin D levels and low BMD (r = 0.473; P < 0.05). Overall, 114/369 (30%) athletes had low BMD and out of these 114 athletes, 108 (95%) were Vitamin D deficient. Serum PTH levels were found to have inverse relations with both Vitamin D (r= -0.629) and BMD (r=-0.267). CONCLUSIONS: Vitamin D deficiency is highly prevalent among the North Indian athletes and the presence of low Vitamin D (<20 ng/ml) levels is associated with low BMD and high PTH levels.

Strong association of meniscus tears with complete Anterior Cruciate Ligament (ACL) injuries relative to partial ACL injuries.

BACKGROUND: Anterior Cruciate Ligament (ACL) injuries are often associated with meniscus tears. These meniscus tears in long term may affect the functional outcomes after ACL reconstruction. The present study aims to identify the incidence and relative association of meniscus injuries in complete and partial ACL injuries. METHODS: This was a retrospective study. Patients were divided into 2 groups; group I: partial ACL tear and group 2: complete ACL tear. Both groups were assessed for meniscal tears; either isolated medial/lateral or combined and odds ratio was measured between two groups. RESULTS: A total of 43 and 219 patients were enrolled in group I and II respectively. The mean age (years) in group I and II were 25.32 ± 7.12 and 28.64 ± 10.84 respectively. There were a total of 5 and 28 females in group I and II respectively. Mean pre-injury Tegner score in group I and II was 7.02 ± 2.87 and 6.82 ± 3.14 respectively. Mean time from injury to surgery (months) in group I and II was 8.04 ± 6.43 and 7.62 ± 4.83 respectively. In group 1 There were a total of 6 with lateral meniscus tears, 9 with medial meniscus tears And 3 with combined meniscal tears in group 1 while in group 2, 47 had lateral meniscal tears, 71 had medial meniscal tears and 71 had combined tears. Group II patients had stronger association for isolated meniscal tears compared to group I, with an odds ratio of 5.05(p < 0.05). Combined meniscal tears had non-significant relation in two groups (p = 0.58). CONCLUSION: Partial ACL injuries present with less risk of acquiring isolated meniscus tears, compared to complete ACL injuries.

There is an Association of Synovial Interleukin-6 Levels With Chondral Damage in Anterior Cruciate Ligament-Deficient Knees.

Background: Osteoarthritis (OA) in the anterior cruciate ligament (ACL)-deficient knee is seen in approximately 50% of affected patients. Possible causes include biochemical or biomechanical changes. Purpose: We sought to study the correlation between inflammatory cytokines and chondral damage in ACL-deficient knees. Methods: Seventy-six male patients who underwent ACL reconstruction were enrolled in a cross-sectional study. Synovial fluid was aspirated before surgery and analyzed for levels of the inflammatory cytokines tumor necrosis factor-α, interleukin-1 (IL-1), and interleukin-6 (IL-6). At the time of ACL reconstruction, the severity of chondral damage was documented as described by the Outerbridge classification. Results: Patients with grade 2 or higher chondral damage were observed to have elevated IL-6 levels when compared to patients who had no chondral damage. Interleukin-6 levels had no correlation with the duration of injury. Conclusion: Elevated levels of IL-6 in synovial fluid were associated with chondral damage in ACL-deficient knees. Further study is warranted to determine whether inflammatory cytokines contribute to the development of OA of the knee after ACL injury.

Pre-operative Joint Inflammation has no Bearing on Outcome of Arthroscopic Anterior Cruciate Ligament Reconstruction at 1-Year Follow-Up; a Prospective Study.

BACKGROUND: To study the effect of pre-operative joint inflammation on clinical outcome at 1 year follow-up following ACL reconstruction surgery. METHODS: Male patients, aged 18-40 years, suffering from isolated ACL injury were included. All patients were randomly divided into two groups based on the type of graft used: Group A: semitendinosus gracilis graft with preserved insertions (STG-PI), Group B: bone-patellar tendon-bone graft (BPTB). Patients were categorised based on the time of presentation after injury: (a) within 6 weeks of injury, (b) between 6 and 12 weeks of injury, (c) after 12 weeks of injury. Synovial fluid levels of Interlukin-1, Interlukin-6 and TNF-α were measured in all the ACL deficient knees by taking a joint fluid sample intra-operatively. RESULTS: The total number of patients in the study was 59; 23 in group A (STG-PI) and 36 in group B (BPTB). Mean age of patients was 26 ± 5.146 years. 14 out of 59 (23.7%) patients presented within 6 weeks of injury, 16 (27.11%) patients presented between 6 and 12 weeks after injury and 29 (49.1%) patients presented after 12 weeks of injury. IL-6 levels were significantly high in group with < 6 weeks of injury than in group with > 12 weeks since injury. IL-6 had significant correlation with VAS scores, KT 1000, Lysholm knee scores and Tegner level of activity. There was no difference in outcome (pain scores, mechanical stability, Lysholm knee score and Tegner level of activity) at 1 year follow-up when patients with different time intervals since injury were compared. CONCLUSION: The clinical outcome in terms of pain score, mechanical stability, functional scores and return to sporting activity is comparable, irrespective of the time since injury, at short term follow-up.

Femoral tunnel length has no correlation with graft rupture: A retrospective cohort study.

BACKGROUND: Literature is controversial on femoral tunnel length as a risk factor for graft injury if the graft length in the tunnel is kept constant at ≥15 mm. METHODS: A total of 1079 sportspersons, meeting our inclusion criteria, were assessed for graft rupture. Patients with femoral tunnel length (FTL) ≤30 mm were labeled as Group 1, while those with FTL > 30 mm were labeled as Group 2. Both groups were compared for potential risk factors for graft injury keeping graft length in the tunnel at ≥15 mm and statistical analysis was performed to study whether the femoral tunnel length acted as an additional risk factor. RESULTS: Of 1079 sportspersons, 37 suffered from graft rupture. Patients with FTL > 30 mm were included in Group 1(n = 22) and patients with FTL ≤ 30 mm (n = 15) were included in Group 2. Both groups were comparable for risk factors for ACL injury: age (P = 0.37), gender (P = 0.53), mode of re-injury (P = 0.38), graft diameter (P = 0.71), level of sports activity (P = not significant), duration from injury to index surgery (P = 0.74), duration from index surgery to re-injury (P = 0.52), timing of return to sports after index surgery (P = 0.30), duration of sporting activity before second injury (P = 0.31), Tegner's level (P = not siginificant), Notch width index (P = 0.12) posterior slope (P = 0.77) and height (P = 0.41). CONCLUSION: Because the graft length in the tunnel was kept at optimum and the risk factors for ACL injury were comparable in both groups at a follow up period, we suggest that femoral tunnel length is not a risk factor for graft failure.

Vitamin D deficiency in athletes and its impact on outcome of Anterior Cruciate Ligament surgery.

BACKGROUND: Vitamin D deficiency is a worldwide pandemic problem. With vitamin D having some role in exercise-induced inflammation, skeletal muscle mass and endurance, we studied its effect on functional outcome of athletes' post-Anterior Cruciate Ligament (ACL) reconstruction. METHODS: A total of 153 patients who underwent primary ACL reconstruction were enrolled in the study. All patients were screened for vitamin D levels preoperatively. Patients were divided into 3 groups on basis of vitamin D levels; Group 1 patients had < 20 ng/ml, group 2 patients 20-30 ng/ml and group 3 > 30 ng/ml. All patients were followed up for a minimum of 2 years. RESULTS: A total of 153 patients were enrolled in study. The average age of the patients was 24.12 ± 2.12 years in group 1, 25.24 ± 3.20 years in group 2 and 24.74 ± 2.86 in group 3. The mean follow-up of patients was 2.8 ± 1.2 years. At 2 years, the mean Lysholm score was 96.12, 96.49 and 97.0, respectively (p = 0.75); mean WOMAC score was 3.33, 3.38 and 3.20, respectively (p = 0.91); mean difference between the pre-injury and post-surgery Tegner level of sports activity at 2 years follow-up was 0.78, 0.78 and 0.85, respectively (P = 0.51) and graft failure rate was 5.88%, 1.96% and 1.96%, respectively (p = 0.43). CONCLUSION: Vitamin D has no effect on functional outcome and graft rupture rates in patients' post-primary ACL reconstruction. LEVEL OF EVIDENCE: Prospective Cohort Study (Level III).

Unusual Combination of Hip Dislocation with Ipsilateral Femoral Neck and Acetabulum Fracture: A Rare Case Report.

Introduction: Traumatic dislocation of hip associated with ipsilateral femur neck and acetabulum fracture is a rare and devastating injury as a result of high-energy trauma, with potential complications of femur head aseptic necrosis and hip joint degenerative arthritis. Patients, postoperatively, may encounter decreased functional outcomes and serious challenge, during activities of daily living. Management guidelines lack clarity, with possible options including fracture fragments fixation or hip joint replacement. Case Report: A 45-year-old patient was diagnosed with posterior dislocation of hip with ipsilateral femur neck and acetabulum fracture. Plan for emergent hip reduction and primary surgical fixation of fracture fragments was made. Intraoperatively, posterior wall acetabulum fracture was found to be excessively comminuted and non-amenable for fixation and femoral head was found to be avascularized. Subsequently, plan was changed to total hip replacement with acetabular defect reconstruction. At 1-year follow-up, no aseptic loosening was observed on radiographic views of pelvis, with total Harris Hip Score of 91. Conclusion: Early operative management for such complex injuries is a necessity. Definitive management in the form of primary fracture fixation/arthroplasty should be decided intraoperatively.

Effect of COVID-19 on surgical management of open fractures and infection rates: A tertiary care experience in Indian set-up.

BACKGROUND: Open fractures form one of the most common musculoskeletal injuries and are often complicated by infection. In this unprecedented situation, the additional infection rates, further add to the burden of the already compromised healthcare setup. The present study is done to see the effect of COVID-19 on management of open fractures. METHODS: A retrospective evaluation of patients with open fractures from March 25th, 2020 to July 21st, 2020 (group 1) and March 25th, 2019 to July 21st, 2019 (group 2) was performed. These patients were assessed for demographic details, diagnosis, type of surgery, delay from injury to admission, delay from admission to surgery, postoperative hospital stay, acute infection rates, readmission rates and associated injuries. RESULTS: A total of 52 patients with 59 open fractures in 2020 and 89 patients with 101 open fractures in 2019 met the inclusion criteria. The mean age was 34.76 years and 32.74 years in 2020 and 2019 respectively. Road side accidents were predominant in both the groups, comprising of 38 (73.07%) and 67 (75.28%) respectively(n.s.); adult patients were 42 (80.76%) and 79 (88.76%) respectively(n.s.); paediatric patients were 10 (19.23%) and 10 (11.23%) respectively(n.s.); tibia was the most common bone involved, comprising of 14 (23.72%) and 27 (26.73%) open fractures respectively(n.s.); external fixator was the most commonly used implant during COVID-19 time with 42 (71.18%) and 51 (50.49%) respectively(p = 0.005); the infection rate was 25.42% and 20.79% respectively(n.s.); the time for administration of first intravenous antibiotic dose was on 6.75 h and 4.04 h respectively(p < 0.0001); average time between the admission and surgical debridement was 24.04 h and 19.32 h respectively(n.s.); referral cases were 33 (63.46%) and 44 (49.43%) respectively(n.s.); re-admission rates were 7/52 (13.46%) and 10/89(11.23%) respectively(n.s.). CONCLUSION: Despite the decrease in total trauma cases, a delay in presentation to the emergency room/administration of first dose of antibiotic and increase in temporary fixation in form of external fixator was observed. Further, an increase in infection rates, referral cases and readmission rates were observed, though not statistically significant.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion": A Randomized Clinical Trial.

BACKGROUND: The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction. PURPOSE: This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft. MATERIALS AND METHODS: One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score. RESULTS: Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain. CONCLUSION: There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Anterior cruciate ligament tear due to non-contact mode of injury associated with higher incidence of meniscal and chondral damage.

BACKGROUND: Forces acting on the knee are different in contact and non-contact mode of injuries causing anterior cruciate ligament (ACL) tear. Purpose of this study was to determine the effect of mode of injury on the occurrence of meniscal tear and chondral damage in ACL tear. METHOD: 72 athletes with acute ACL injury (<3 months) were enrolled in the study. Depending on the mode of injury, athletes were divided into two groups - group A (non-contact mode of injury) and group B (contact mode of injury). 49/72 athletes had the non-contact mode of injury (group A), and 23/72 athletes had contact mode of injury (group B). Meniscal tear and chondral damage seen at the time of ACL reconstruction surgery was noted. All athletes were assessed at 12 months follow-up for return to sports, Lysholm score, and WOMAC score. RESULTS: In group A, 35/49 (71%) athletes and in group B, 9/23(39%) athletes had meniscal tear (p = 0.009). Medial meniscus was more commonly injured in group A [24/49] as compared to group B (5/23; p = 0.03). Chondral damage was also more commonly seen in group A [26/49] as compared to group B (5/23; p = 0.01). At one-year follow-up, 65% of the athletes from group B returned to sports as compared to 57% of the athletes from group A (p-value = 0.6). WOMAC score in group A and B was 95.5 ±â€¯4.88 and 96 ±â€¯4.39 respectively (p = 0.67). Lysholm score in group A and B was 1.02 ±â€¯1.7 and 0.96 ±â€¯1.2 respectively (p = 0.88). CONCLUSION: Non-contact mode of injury was associated with a higher incidence of meniscal tear and chondral damage. However, the mode of injury does not affect the functional outcome of ACL reconstruction surgery.

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft is associated with higher and earlier return to sports as compared to hamstring tendon graft.

PURPOSE: To study the effect of age, duration of injury, type of graft and concomitant knee injuries on return to sports after anterior cruciate ligament (ACL) reconstruction. METHOD: One-hundred and sixteen athletes underwent ACL reconstruction using either bone-patellar tendon-bone graft (BPTB; n = 58) or semitendinosus-gracilis graft (n = 58), depending upon their random number sequences. Five variables were analyzed in terms of their effect on return to sports-age, type of graft, time interval between injury and surgery, chondral damage and meniscal tears. RESULTS: Fifty-three out of 73 (72.6%) athletes aged between 16 and 25 years and 21/43 (49%) athletes aged between 25 and 40 years returned to sports (p = 0.02). The mean time to return to sports was 9.7 ± 2.1 months and 10.8 ± 1.7 months in athletes aged < 25 years and 25-40 years, respectively (p = 0.04). ACL reconstruction with BPTB graft (43/58) was associated with higher rate of return to sports as compared to hamstring tendon graft (31/58; p = 0.02). The mean duration of return to sports with BPTB and STGPI graft was 9.7 ± 2.0 months and 10.7 ± 2.0 months, respectively (p = 0.02). 29/36 (80.5%) patients operated between 2 and 6 months, 18/29 (62%) operated in < 2 months, and 27/51 (53%) operated after 6 months of injury had returned to sports (p = 0.03). Athletes who were operated within 2 months of the injury were the earliest to return to sports (9.4 ± 2.1 months), followed by those operated within 2-6 months (9.9 ± 1.9 months) and lastly by the ones operated after 6 months of the injury (10.9 ± 2.1 months; p = 0.04). CONCLUSIONS: The rate of return to sports was observed to be higher in athletes younger than 25 years as compared to older athletes (> 25 years). ACL reconstruction with BPTB graft was associated with higher and earlier returns to sports as compared to hamstring graft. The rate of return to sports was highest if surgery was performed between 2 and 6 months after the injury. LEVEL OF EVIDENCE: III.

Comparing the Role of Different Treatment Modalities for Plantar Fasciitis: A Double Blind Randomized Controlled Trial.

INTRODUCTION: Although many treatment modalities including rest, stretching, strengthening, change of shoes, arch supports, orthotics, night splints and anti-inflammatory agents have been advocated for plantar fasciitis, there is no report in the literature which compares the independent effectiveness of each treatment modality without the concomitant use of any other one. METHODS: A double blind, randomized controlled study was undertaken where 140 patients of plantar fasciitis were divided into four groups with 35 patients each. Patients in four groups received analgesics, hot water fomentation and silicon heel pads, plantar fascia stretching and calf stretching exercises, respectively. Heel pain was evaluated using Foot Function Index (FFI) and disability using Foot and Ankle Disability Index (FADI). Clinical evaluation was done weekly up to a period of 4 months and then at 6 months, 8 months, 10 months and 12 months. RESULTS: Mean age of patients was 43.4 ± 10.6 years with average duration of symptoms being 27.26 weeks (range 4-200 weeks). Both FFI and FADI showed statistically significant improvement at 12 months in all the four groups (p value < 0.0001 for all groups). However, groups 2, 3 and 4 were observed to show statistically better results in terms of heel pain reduction (FFI) as compared to group 1 (ANOVA, p value < 0.0001 for group 1 vs. 2, group 1 vs. 3 and group 1 vs. 4). In terms of disability (FADI), best results were observed in group 3. CONCLUSION: Plantar fascia stretching exercises resulted in most significant improvement in both the scores (FFI and FADI), followed by treatment with heat and silicone heel pad and calf stretching exercises.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion:" A Randomized Clinical Trial.

BACKGROUND: The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction. PURPOSE: This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft. MATERIALS AND METHODS: One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score. RESULTS: Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain. CONCLUSION: There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Is anterior cruciate ligament graft rupture (after successful anterior cruciate ligament reconstruction and return to sports) actually a graft failure or a re-injury?

PURPOSE: The objective of this study is to discuss the fact that whether graft rupture after successful anterior cruciate ligament (ACL) reconstruction surgery is due to graft failure or re-injury to the reconstructed ACL. METHODS: In total, 340 sportspersons, meeting our inclusion criteria, were assessed for rupture of ipsilateral ACL graft and ACL injury of the contralateral knee. Patients with ipsilateral ACL graft rupture were labelled as group 1, while those with contralateral ACL injury were labelled as group 2. Both groups were compared for potential risk factors for ACL injury, and statistical analysis was performed to study whether the graft acted as an additional risk factor. RESULTS: Of the 340 sportspersons, 25 patients suffered a total of 26 injuries. Ipsilateral graft rupture rate was 2.4% (8 of 340) at a mean follow-up of 25.5 ± 40.57 months, and the contralateral ACL injury rate was 5.3% (18 of 340) at a mean follow-up of 18.11 ± 19.97 months, with an overall re-injury rate of 7.6%. Both groups were comparable for risk factors for ACL injury: age ( p = 0.255), gender ( p = 0.534), mode of re-injury ( p = 0.523), level of sports activity, type of graft used ( p = 0. 918), graft diameter ( p = 0.607), duration from injury to index surgery ( p = 0.492), duration from index surgery to re-injury ( p = 0.638), timing of return to sports after index surgery ( p = 0.303), duration of sporting activity before second injury ( p = 0.657), and Tegner's level of sports activity ( p = 0.486). CONCLUSION: Because the rate of contralateral ACL injury is higher than the ipsilateral graft rupture and the risk factors for ACL injury are comparable in both groups at a follow-up period, which is suggestive of ligamentization of the graft, we suggest that it might be an ACL re-injury rather than graft failure. Level of Evidence: Level III (Retrospective cohort study).

The role of meniscal tears and meniscectomy in the mechanical stability of the anterior cruciate ligament deficient knee.

BACKGROUND: The role of an intact meniscus in providing mechanical stability to the knee of anterior cruciate ligament (ACL) deficient and ACL reconstructed patients has not been well studied. METHODS: This was a prospective cohort study. A total of 205 patients undergoing ACL reconstruction were enrolled, of which 61 had normal menisci, 49 had a tear in the posterior horn of the medial meniscus (PHMM) (tear <40% of width = 19; >40% of width = 30), 35 had a tear in the lateral meniscus (<40% of width = 15; >40% = 20), 13 had a tear in the body and/or anterior horn of the medial meniscus (<40% of width = 6; >40% = 7) and 47 patients had a tear in both menisci. Patients with a tear in both menisci were excluded. The anterior translation of the tibia (ATT) was calculated preoperatively and postoperatively at three months and six months using KT-1000. Partial meniscectomy was performed in all unstable meniscal tears. RESULTS: The mean age at the time of surgery was 25.2 ±â€¯5.1 years. Patients with a normal meniscus showed side to side difference in KT-1000 of 4.8 ±â€¯2.5 mm whereas those with a <40% tear and >40% tear in PHMM had a difference of 5.36 ±â€¯3.07 mm (P = 0.46) and 7.08 ±â€¯2.78 mm (P = 0.0002), respectively. Patients with a lateral meniscus <40% and >40% tear had a mean difference of 5.68 ±â€¯2.96 mm (P = 0.22) and 5.95 ±â€¯2.39 mm (P = 0.09), respectively. Patients with body and/or anterior horn of medial meniscus <40% and >40% had a difference of 5.41 ±â€¯1.11 mm (P = 0.59) and 5.78 ±â€¯2.38 mm (P = 0.35), respectively. At three months and six months KT-1000 differences of 2.3 ±â€¯1.2 mm and 2.1 ±â€¯1.2 mm were seen in patients with normal meniscus; 2.26 ±â€¯1.51 mm and 2.16 ±â€¯0.9 mm with partial meniscectomy of the PHMM <40%; 2.65 ±â€¯1.53 mm and 2.4 ±â€¯1.35 mm with partial meniscectomy of the PHMM >40%; 2.27 ±â€¯1.19 mm and 2.07 ±â€¯1.52 mm with partial meniscectomy of the lateral meniscus <40%; and 2.27 ±â€¯1.44 mm and 2.07 ±â€¯1.14 mm with partial meniscectomy of the lateral meniscus >40%; 2.55 ±â€¯1.56 mm and 1.91 ±â€¯1.09 mm with partial meniscectomy in body and/or anterior horn of medial meniscus <40% and 2.07 ±â€¯1.81 and 2.14 ±â€¯1.10 mm with partial meniscectomy in body and/or anterior horn of medial meniscus >40% (P > 0.05). CONCLUSION: PHMM acts as a secondary stabilizer of the knee joint in the absence of functional ACL. There is no effect of partial meniscectomy on mechanical stability of the knee in ACL reconstructed patients. Medial or lateral partial meniscectomy performed at the time of ACL reconstruction does not affect the stability of ACL reconstructed knee. However, the presence of a concomitant tear in PHMM is associated with increased instability in ACL deficient knee.