Pediatric Forearm Fractures: Investigating the Functional Outcomes of Titanium Elastic Nailing for Unstable Both-Bone Fractures.

Introduction: Diaphyseal forearm fractures pose a common challenge in children and adolescents, impacting forearm function due to rotational deformities and angulation. The landscape of pediatric forearm fracture treatment has seen limited progression, with increased surgical intervention adoption driven by factors such as functional implications, technological advancements, societal expectations, and legal concerns. Materials and Methods: This study enrolled consecutive children aged 5-16 years with forearm fractures presenting between August 2018 and January 2020, requiring surgical intervention. The study assessed functional outcomes and complications in children treated with titanium elastic nailing. Results: Sixteen patients underwent surgery for both-bone forearm fractures. Elastic nailing was the primary intervention, with 75% undergoing closed nailing. Patients' ages ranged from 5 to 15 years, with 87.5% being male. The study evaluated fracture characteristics, surgical procedures, post-operative care, and complications. Conclusion: The study demonstrates promising outcomes for flexible intramedullary nailing in pediatric forearm fractures. Despite the observed complications, the majority of cases achieved excellent results in fracture union and patient recovery, supporting the efficacy of this technique. Larger cohorts are needed for a comprehensive understanding of its applicability and outcomes in pediatric forearm fracture management.

Role of Doxycycline as an Osteoarthritis Disease-Modifying Drug.

Doxycycline is a drug that has been proposed to modify osteoarthritis (OA) progression, in addition to its role as an antibiotic. However, available evidence thus far comprises sporadic reports, with no consensus on its benefits. Hence, this review attempts to analyze the evidence available thus far on the role of doxycycline as a disease-modifying osteoarthritis drug (DMOAD) in knee osteoarthritis. The earliest evidence of doxycycline in OA appeared in 1991 when doxycycline was found to inhibit the type XI collagenolytic activity of extracts from the human osteoarthritic cartilage, and gelatinase and tetracycline were found to inhibit this metalloproteinase activity in articular cartilage in vivo, which could modify cartilage breakdown in osteoarthritis. Apart from the inhibition of cartilage damage by metalloproteinases (MMPs) and other cartilage-related mechanisms, doxycycline also affects the bone and interferes with many enzyme systems. The most significant finding after reviewing various studies was that doxycycline has a definitive role in structural changes in osteoarthritis progression and radiological joint space width, but its role in the improvement of clinical outcomes as a DMOAD has not been established. However, there is much of a gap and lack of evidence in this regard. Doxycycline, as an MMP inhibitor, has theoretical advantages for clinical outcomes, but the present studies reveal only beneficial structural changes in osteoarthritis and very minimal or nonexistent advantages in clinical outcomes. Current evidence does not favor the regular use of doxycycline for the treatment of osteoarthritis as an individual treatment option or in combination with others. However, multicenter large cohort studies are warranted to determine the long-term benefits of doxycycline.

Volume index as a new measure of cartilage loss: a retrospective MRI-based study of chondral injury patterns in adult patients with knee pain.

BACKGROUND: Knee pain is one of the commonest symptoms in patients who attend the Orthopaedic outpatient clinics. Chondral defects result in a painful knee. Incidence of chondral defect is reported to be between 5 and 10% over the age of 40. It is well documented that chondral defects can lead to osteoarthritis. Early detection of these lesions and cartilage repair surgery can delay the onset of osteoarthritis. The purpose of this study is to highlight the incidence, associations and correlations between opposing cartilage defects in patients who present to the knee clinic with pain. METHODS: A retrospective analysis was carried out on patients who had Magnetic Resonance Imaging scans for painful knees between June 2017 and May 2019. About 227 consecutive knees were studied for the incidence of chondral defects, number of lesions, grade and size of lesion, geographical location and associated pathology in the knee. RESULTS: All the 227 patients had chondral lesions. Most patients had 2-3 lesions (66.1%) with patellar lesions (76.6%) being the commonest followed by medial femoral condyle (59.9%). Significant correlation was found in grade and size between opposing surface lesions in patella-trochlea, Medial Femoral Condyle-Medial Tibial Plateau and Lateral Femoral Condyle-Lateral Tibial Plateau. Females were more predisposed to patella lesions. Significance between age and lesions were established. CONCLUSION: Incidence of cartilage defects in the knee is very high. Kissing lesions must be considered when treating cartilage lesions. Volume index could be a promising method to quantify lesions.

Spontaneous Osteonecrosis of the Knee: State of the Art.

Osteonecrosis is a terrible condition that can cause advanced arthritis in a number of joints, including the knee. The three types of osteonecrosis that can affect the knee are secondary, post-arthroscopic, and spontaneous osteonecrosis of the knee (SPONK). Regardless of osteonecrosis classification, treatment for this condition seeks to prevent further development or postpone the onset of knee end-stage arthritis. Joint arthroplasty is the best course of action whenever there is significant joint surface collapse or there are signs of degenerative arthritis. The non-operative options for treatment at the moment include observation, nonsteroidal anti-inflammatory medications (NSAIDs), protective weight bearing, and analgesia if needed. Depending on the severity and type of the condition, operational procedures may include unilateral knee arthroplasty (UKA), total knee arthroplasty (TKA), or joint preservation surgery. Joint preservation techniques, such as arthroscopy, core decompression, osteochondral autograft, and bone grafting, are frequently used in precollapse and some postcollapse lesions, when the articular cartilage is typically unaffected and only the underlying subchondral bone is affected. In contrast, operations that try to save the joint following significant subchondral collapse are rarely successful and joint replacement is required to ease discomfort. This article's goal is to summarise the most recent research on evaluations, clinical examinations, imaging and various therapeutic strategies for osteonecrosis of the knee, including lesion surveillance, medicines, joint preservation methods, and total joint arthroplasty.

Injectable cultured bone marrow derived mesenchymal cells vs chondrocytes in the treatment of chondral defects of the knee - RCT with 6 years follow-up.

Articular cartilage has unique biological and biomechanical characteristics. Damage to this tissue fails to heal spontaneously, leading to progressive arthritis. Cartilage repair techniques have been looked forward to in the treatment of significant cartilage injuries. Cell-based regenerative techniques like the two-staged cultured chondrocytes and single-stage mesenchymal cell transplantation have been tried with varying results and limitations. We study the outcomes of cultured bone marrow derived MSCs in the treatment of articular cartilage defects of the knee in comparison to autologous cultured chondrocyte implantation (ACI). Both cultured MSC and ACI treatment methods resulted in significant improvements in patient reported outcome measures (PROMs). There was no difference in the PROMs, MOCART scores, T2∗ mapping and dGEMRIC values between the groups. Use of cultured MSCs leads to good clinical outcomes similar to ACI and represents a promising treatment to restore the articular cartilage in the knee.

Biological reconstruction of the joint: Concepts of articular cartilage regeneration and their scientific basis.

Articular cartilage injuries are common. The diagnosis of these injuries is often delayed and may lead to early osteoarthritis. Treatment depends on many factors but mainly on the stage and size of the lesion. The anatomy of articular cartilage is complex, and it is an avascular, aneural, and alymphatic structure. Recently, more emphasis is laid on its anatomy and biomechanics to understand the regeneration process of articular cartilage.

Meniscal Extrusion: A Narrative Review.

BACKGROUND: Meniscal extrusion, referred to as an external displacement of the meniscus, is a commonly encountered but often overlooked magnetic resonance imaging finding in the knee joint. Meniscal extrusion alters the biomechanical properties of the meniscus, leading to accelerated cartilage degeneration and early osteoarthritic changes. The literature contains discrepancies about meniscal extrusion on topics ranging from definition to diagnosis. This narrative review outlines the pathogenesis, natural history, diagnosis, and treatment of meniscal extrusion. PURPOSE: To review the current literature on meniscal extrusion, from pathogenesis to treatment, and to provide recommendations for future research. STUDY DESIGN: Narrative review. METHODS: A computer-based search of the PubMed, Ovid Medline, and Cochrane Library databases was used to perform a comprehensive literature review on meniscal extrusion. A total of 81 studies was ultimately included in the review. RESULTS: The literature review highlighted the current ambiguity in definition, difficulty in clinical diagnosis, and low level of awareness of this condition. This review covers all aspects related to meniscal extrusion and identifies many of its lesser known aspects. CONCLUSION: In the current literature, meniscal extrusion remains a lesser known albeit common condition because of its relatively silent nature along with lack of knowledge among orthopaedic surgeons. Further studies are warranted to provide better understanding and management of this condition.

Articular cartilage repair & joint preservation: A review of the current status of biological approach.

The articular cartilage of the joint is the thin viscoelastic layer of the connective tissue. It has a unique anatomy and physiology, which makes the repair of the articular cartilage damage more difficult and challenging due to its limited healing capacity. Increasing knowledge regarding the importance of articular cartilage for joint preservation has led to increased attention on early identification of cartilage damage as well as degeneration in order to delay osteoarthritis. There are various treatment modalities ranging from preventive management, physical therapy, pharmacological, non-pharmacological and surgical treatments exist in current literature. However most of the studies have limited long term follow up and mainly consists of small case series and case reports. This is an up to date concise review discussing the available management options for articular cartilage damage starting to lifestyle modification to pharmacotherapy, physiotherapy, and osteobiologics till various joint preservation techniques that have been in use currently.

Floating knee injuries - An analytical study using a conglomerated comprehensive classification.

PURPOSE: Floating knee injuries are complex high velocity injuries with a simultaneous breach of skeletal integrity both above and below the knee joint. Intraarticular fractures, severe comminution, soft tissue insult, associated other skeletal and systemic injuries have been the most common factors influencing the outcome. With our previous experience we framed a conglomerated comprehensive classification, which includes important prognosticating factors that influences the outcome. Aim of this study is to analyse the efficacy of this classification system for floating knee injury by studying the duration of hospitalisation, number of procedures required for completion of treatment, prognosticating functional outcomes and complications. METHODS: This classification is a conglomeration of the existing standard classifications (Fraser, AO, Gustilo and Andersons) along with modifiers like disruption of exensor mechanism M1, avulsion fractures around knee M2 and fractures around hip and ankle joints M3. This classification system was applied to all FKI cases presented to our institution between 2015 and 2018, it has 4 types, 3 subtypes and 3 modifiers. 92 cases were prospectively analysed, the standard treatment protocol was followed as per flowchart, only stable and borderline stable patients were included, functional outcome and recovery of these patients was assessed using modified Karlstrom and Olerud scoring after fracture union. Demographic data, duration of hospitalisation, number of procedures required for completion of treatment, functional outcomes and complications were collected and statistical analysis was done. RESULTS: Statistical Analysis showed significant difference between groups I and IV of conglomerated comprehensive classification in the number of days of hospitalisation and number of procedures with p value 0.006 and 0.018 respectively. CONCLUSION: Conglomerated comprehensive classification using prognostic factors and existing standard classifications enables better prognostication of these complex floating knee injuries. Identifing and addressing these factors and modifiers included in this classification system will surely improve the outcome. A multicentric study will validate this classifaction in a better way.

Hajdu-Cheney Syndrome: A Report on Successful Halting of Acro-osteolysis.

CASE: The phenomenon of acro-osteolysis often intrigues clinicians and patients alike, as it causes bone resorption. One such condition is Hajdu-Cheney syndrome. We report our experience in identifying and halting the active bone resorption in a patient and his father with 2-year follow-up results. CONCLUSION: Management included identification of the NOTCH2 mutation and treatment with antiresorptive measures. In addition, genetic counseling and antenatal counseling are recommended to explain the risk of inheritance.

Assessment of safety and efficacy of intra-articular injection of stromal vascular fraction for the treatment of knee osteoarthritis-a systematic review.

PURPOSE: Stromal vascular fraction (SVF) as an injectable regenerative therapy for knee osteoarthritis (OA) has gained recent popularity. However, there is no clear consensus on the outcomes of such treatment. We systematically reviewed available evidence on the use of SVF injection in the treatment of knee OA. METHODS: The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, with keyword search in PubMed, Scopus, and the Cochrane Library Database and related article search in Google Scholar. Clinical studies demonstrating effects of SVF in knee OA and published in English literature were included. Risk of bias assessment was done with modified Coleman Methodology Scoring (CMS). RESULTS: Eleven studies (9 prospective, 2 retrospective) that contributed to 290 knees in 200 patients were included. Two studies that contributed to 3718 knee injections were excluded from pooled analysis and were scrutinized separately. Majority of patients reported improvement in pain, range of motion (ROM), functional rating, six metre walking distance, and functional outcome scores. There was no major donor-site morbidity. There was only one reported case of knee joint infection and no case of tumour formation in relation to SVF injection. DISCUSSION: Intra-articular injection of SVF can be a simple, affordable, and minimally invasive treatment that could serve as an interim option for patients who failed other conservative and arthroscopic options. CONCLUSION: Intra-articular injection of SVF is a safe and effective technique for the management of knee OA. However, comparative Level I studies are needed to support the use of adjuvants with SVF and also to compare the use of SVF (with or without adjuvants) with ADMSCs, PRP, and bone marrow concentrate.

Successful two-stage primary total knee arthroplasty for infective arthritis of the knee - our experience.

BACKGROUND: The incidence of septic arthritis is 2-10/100,000. Morbidity is higher with persistent joint dysfunction in up to 30%. Osteoarthritic knee with infection presents a rare challenge, with no established approach for treatment exists. We present our experience of managing infected degenerative joint disease (DJD) with two-stage primary arthroplasty similar to the management of periprosthetic joint infection. PATIENTS AND METHODS: Four patients presented to us between 2016 and 2018 with advanced DJD associated with coexistent joint sepsis with or without adjacent osteomyelitis. The diagnosis of joint sepsis with periarticular osteomyelitis was made based on clinical presentation, radiographic findings, inflammatory serological markers, and culture of knee joint aspirate. All were operated with primary arthroplasty in two stages of debridement with a static spacer followed by antibiotics and implantation. DISCUSSION: With no established method of treating DJD superadded with infection, our experience adds valuable information in treating the same. Our 2-staged primary arthroplasty had a short antibiotic duration between stages, a mean of 63.5 days, and stopped within 3 days of 2ndstage reducing hospital stay, morbidity, and cost.Our approach is a very viable method of treating infected DJD with a minimum drug holiday time of two weeks before implantation with a better outcome, reducing the recurrence rate of infection.Though a small number with a minimum follow-up of 24 months, we believe we provide valuable additional information. CONCLUSION: All patients had painless return to early activities with no signs of recurrent infection. Our approach is a very viable and could serve as a cost-effective method treatment for an infected arthritic knee.

Extraarticular extrasynovial solitary osteochondromatosis of the ankle: A rare case report and review of literature.

INTRODUCTION: Synovial chondromatosis (SC) is a relatively common benign condition of the synovial joint characterized by the formation of cartilaginous nodules in synovium. However, extra articular osteochondromatosis is rare and only few have been reported around the ankle joint. We have reported such a presentation and have reviewed the literature extensively. PRESENTATION OF CASE: We present a 26 year old male patient with a painless swelling over the lateral aspect of his left ankle. He was subjected to clinical and radiological examination which revealed a firm to hard swelling around the lateral malleolus and a lobulated juxtacortical cystic lesion with calcification. He underwent a surgical excision and subsequent histopathology was suggestive of SC. DISCUSSION: The subtle clinical and radiological presentation of SC can lead to both a delay in the diagnosis and a diagnostic dilemma if suspicion is low. Early meticulous diagnosis and management can curtail morbidity. CONCLUSION: The degree of suspicion needs to be high to diagnose the condition early to prevent both morbidity and inadequate treatment. Histopathological corroboration is needed to rule out uncommon but possible malignant transformation, notably in long standing cases.

Cyclops Lesions of the Knee: A Narrative Review of the Literature.

Cyclops lesion is a known complication of anterior cruciate ligament reconstruction (ACLR). Although the incidence of cyclops lesion appears to be decreasing, it remains an important cause of restriction of extension after ACLR. We reviewed the available literature regarding the cyclops lesion and syndrome and cyclops-like lesions to analyze available evidence on cyclops lesions and variants of cyclops lesions. A keyword search in PubMed, Scopus, Web of Science, and EMBASE, Ovid Medline, and Ovid journals provided 47 relevant articles in the English literature, which were used to create this review. We classified cyclops lesions based on clinical presentation, pathology, and location. Risk factors, management options, tips to reduce the condition, and controversies related to the condition have been discussed. Female sex, greater graft volume, bony avulsion injuries, excessively anterior tibial tunnel, double-bundle ACLR, and bicruciate-retaining arthroplasty appear to predispose patients to cyclops lesions. Cyclops syndrome is a cyclops lesion that causes a loss of terminal extension. Arthroscopic debridement is an effective treatment for cyclops syndrome, whereas cyclops lesions are usually managed conservatively. It is important to distinguish between cyclops lesion and cyclops syndrome, as management differs based on symptoms. Cyclops lesion is diagnosed using magnetic resonance imaging. The management of choice for symptomatic lesions is surgical excision. Outcomes after excision are very good, and recurrence is rare.

A Missed Case of Osteoid Osteoma of the Acetabulum Treated with a Novel Computed Tomography-Guided Technique - A Case Report.

INTRODUCTION: Osteoid osteoma is a benign osteoblastic bone tumor that mostly arises from the long bones. The acetabulum is a rare site for osteoid osteoma. Moreover, juxta-articular location of the lesion can be associated with delayed diagnosis. We present a case of a juxta-articular osteoid osteoma of the acetabulum that was missed earlier. We also present a novel, easy, and cost-effective way to accurately localize and excise such a lesion, thereby avoiding failure and recurrence. CASE REPORT: A 15-year-old female presented with a history of insidious onset pain in the right hip for 18 months. Pain was diffuse over the hip. She had undergone a failed biopsy in another hospital. She visited us 1 month later with persistent pain. Examination revealed tenderness over the right anterior hip joint line with painful terminal hip flexion. Computed tomography (CT) suggested an osteoid osteoma of the superolateral acetabular rim. The patient was planned for CT-guided mini-open excision biopsy of the lesion. CT-guided localization of the lesion was performed under local anesthesia in the CT room, followed by open excision of the nidus in the operating room. Histopathology confirmed the diagnosis and a complete excision. At last follow-up at 1 year, the patient was asymptomatic and returned to normal function. CONCLUSION: Osteoid osteoma of the acetabulum is uncommon and the diagnosis is usually delayed. A high index of suspicion is needed to avoid a missed diagnosis and CT-guided approach can help in accurate excision. Our technique to localize and completely excise the lesion is novel, simple, and cost effective and can be easily replicated.

Divergent Fracture-dislocation of Shoulders - A Therapeutic Challenge.

INTRODUCTION: Bilateral shoulder dislocations are rare and can result from sports injuries, epileptic seizures, electric shock, or electroconvulsive therapy. Divergent shoulder dislocations are even more rare and difficult to treat. We report a case of bilateral divergent shoulder dislocations with bilateral greater tuberosity fractures. We have reviewed the existing literature and have summarized the mechanisms and outcomes of such injuries. CASE REPORT: A 35-year-old, right-hand dominant male, a known epileptic presented with pain and deformity in both shoulders after an episode of generalized seizures. Radiographs revealed anterior dislocation on the right and posterior dislocation on the left shoulders along with bilateral displaced fractures of the greater tuberosities. The patient was treated with closed reduction of bilateral shoulder dislocations using gentle traction followed by open suture fixation of the greater tuberosity fractures. The greater tuberosity on the posterior dislocation side needed redo fixation with compression screws and sutures for failed fixation. The patient went on to heal well and achieve full function. The case is one of a very rare group of injuries. CONCLUSIONS: Divergent shoulder injuries with greater tuberosity fractures are very rare. They can present a diagnostic and therapeutic challenge. A higher degree of suspicion to diagnose and patient-based approach with strong fixation techniques can lead to good clinical outcomes.

Inverted Cyclops Lesion of the Knee Associated with a Supracondylar Femoral Nail: A Case Report.

While cyclops lesion, a fibrous nodule on the tibial side of the knee joint, is a well-known condition complicating anterior cruciate ligament, inverted cyclops lesion, a fibrous nodule on the femoral side of the knee, is a relatively less known condition. We report a case of inverted cyclops in a patient who presented with chronic knee stiffness eight years after supracondylar nailing of a femoral shaft fracture. There are only four reported cases of inverted cyclops in literature. Literature has been reviewed and the importance of not missing such a lesion is discussed.