A comparative analysis of arthroscopic double-bundle versus single-bundle posterior cruciate ligament reconstruction using hamstring tendon autograft.

PURPOSE: Anatomically, posterior cruciate ligament (PCL) consists of two bundles, i.e. anterolateral (AL) and posteromedial (PM) bundle. Single-bundle PCL (SBPCL) reconstruction remains most popular method of reconstruction, though double-bundle PCL (DBPCL) reconstruction is more anatomical. This study was done to analyse the clinical and functional outcome after both SBPCL and DBPCL reconstructions using autologous hamstring grafts. METHODS: This was a retrospective study including patients who underwent either DBPCL or SBPCL reconstruction for chronic symptomatic PCL injury. Clinical, functional and radiological evaluation was done pre-operatively and 3 months post-operatively and thereafter at every 6-month interval. Patients with a minimum follow-up of 24 months were included in the study. Pre-operative posterior translation was quantified by manual posterior drawer, KT 1000 measurement and stress radiography. Functional outcome was done using Lysholm and IKDC scores. MRI was done in all patients. RESULTS: Records of 40 patients were available with minimum follow-up of 24 months. Out of these, DBPCL reconstruction was done in 18 patients and SBPCL reconstruction was done in 22 patients. Four patients in DB (double-bundle PCL reconstruction) group and five in SB (single-bundle PCL reconstruction) group had more than grade I laxity by posterior drawer and on KT 1000 measurement DB group had average side-to-side difference of 1.78 mm and SB group 2.44 mm (p value = 0.0487). On functional assessment by Lysholm and IKDC score, there was significant improvement from pre-operative values in both the groups with no significant difference between the groups post-operatively. Stress radiography revealed significantly less post-translation in DB group as compared to SB group. CONCLUSION: Though DBPCL reconstruction results in less posterior laxity, there is no difference in functional outcome of SBPCL and DBPCL reconstructions. LEVEL OF EVIDENCE: III.

A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure.

A neglected shoulder dislocation is a rarer entity and only few cases are reported in the literature. An anterior dislocation of the shoulder is rarely missed as patients present with limb in abduction and external rotation, an attitude very familiar to orthopaedic surgeon. Occasionally such cases are missed when they present with fracture of proximal humerus or when they receive treatment from unqualified practitioners who commonly practise in rural areas. Owing to very few reports there is paucity of literature and no standard treatment protocol exists for neglected anterior dislocation of the shoulder, though most such chronic cases are managed by open reduction. This case report describes a six months old neglected anterior dislocation with a significant Hill Sachs lesion, which was managed by closed reduction and Latarjet procedure.

Subacute posttraumatic ascending myelopathy: A case report and review of literature.

Subacute posttraumatic ascending myelopathy is a rare disorder, unrelated to syrinx formation or mechanical instability, which may gradually emerge within the first 1-2 weeks after a spinal cord injury and may lead to diagnostic and prognostic dilemmas. We present a case of 24-year-old female with unstable wedge compression fracture of L1 vertebrae with signal changes in the upper lumbar cord causing complete paraplegia below D9 with bladder and bowel involvement. In the subsequent week, she developed a delayed progressively increasing neurological deficit with cord signal abnormality on MRI extending cephalad from the injury site to the upper dorsal cord. The patient had no initial clinical improvement initially but showed a delayed recovery over months.

Ankle fusion with centralisation of the fibula after distal tibia bone tumour resection.

BACKGROUND: Management of distal tibial tumours with limb salvage surgery poses a challenge for the orthopaedic surgeon. This study was done to evaluate the results of fibular centralisation as a technique to reconstruct defects that occurred after resection at this site. MATERIALS AND METHODS: Nine patients with a mean age of 23.2 years (range 17-34) with diagnosis of osteosarcoma in four patients, Ewing's sarcoma in two, giant cell tumour in two and chondrosarcoma in one patient underwent surgical treatment for tumour in the distal tibia. All patients had wide resection of the tumour and ankle arthrodesis with centralisation of the fibula. Patients were assessed clinico-radiologically for bone union, infection and complications. The final functional outcome was estimated according to Musculoskeletal Tumor Society (MSTS) scores. RESULTS: The mean age at the time of surgery was 23.2 years (17-34). There were five females and four males. The mean follow-up was 37 months (range 28-54 months). One of the patients with osteosarcoma had a recurrence a year after limb salvage surgery, underwent above-knee amputation, and died 18 months later due to metastasis. One patient developed leg length discrepancy. The mean MSTS score was 22.75 (range 17-27). CONCLUSION: Fibular centralisation is a durable reconstruction tool for defects of the distal tibial metaphysis with an acceptable functional outcome. It is an inexpensive and simple procedure, with a low rate of late complications, and reproducible results. LEVEL OF EVIDENCE: IV Retrospective case series.

Osteosynthesis with long volar locking plates for metaphyseal-diaphyseal fractures of the distal radius.

OBJECTIVE: Metaphyseal-diaphyseal fractures of the distal radius are a major treatment dilemma and orthopaedic surgeons have to pay due consideration to restoration of anatomy of distal radius together with rotation of the radial shaft and maintenance of radial bow and interosseous space. We performed this study to evaluate the clinic-radiological outcome of metaphyseal-diaphyseal fractures of the distal radius treated with long volar locking plates. METHODS: This prospective study involved 27 patients (22 males and 5 females) with metaphyseal-diaphyseal fracture of the distal radius. Their mean age was (30.12+/-11.48) years (range 19-52 years) and the follow-up was 26.8 months (range 22-34 months). All patients underwent open reduction and internal fixation with a long volar locking plate. According to AO/OTA classification, there were 7 type A3, 13 type C2 and 7 type C3 fractures. Subjective assessment was done based on the disabilities of the arm, shoulder and hand (DASH) questionnaire. Functional evaluation was done by measuring grip strength and range of motion around the wrist and the radiological determinants included radial angle, radial length, volar angle and ulnar variance. The final assessment was done according to Gartland and Werley scoring system. RESULTS: Postoperative radiological parameters were well maintained throughout the trial, and there was significant improvement in the functional parameters from 6 weeks to final follow-up. The average DASH scores improved from 37.5 at 6 weeks to 4.2 at final follow-up. Final assessment using Gartland and Werley scoring system revealed 66.67% (n equal to 18) excellent and 33.33% (n equal to 9) good results. There was one case of superficial infection which responded to antibiotics and another carpel tunnel syndrome which was managed conservatively. CONCLUSION: Volar locking plate fixation for metaphyseal-diaphyseal fractures of distal radius is associated with excellent to good functional outcome, early rehabilitation and minimal complications.

Application of Henna as a Durable Skin Marker in Orthopedic Surgery.

Background Many orthopedic procedures require skin marking well before surgery. Marks made with most conventional marking pens fade with vigorous skin preparation required before orthopedic procedures, whereas marks with henna may safely last almost up to three weeks. Thereby, we intend to describe applications of henna, a readily available, cost-effective material, as a durable skin marker for various indications in orthopedics. Methods A total of 120 patients with varied indications for skin marking were randomized into two equal-sized groups of 60 each. Group A patients were marked with henna and group B patients with a permanent skin marker before the intended surgery. All patients had a routine pre-operative bath one day before surgery and vigorous skin preparation using chlorhexidine and ethanol-based scrubs just before surgery in the operating room. The two markers were compared for the following variables: photographic record to determine fading of the mark after scrubbing, in terms of successful execution of the procedure, patients' acceptability of the mark, any allergy or infection, and final time of disappearance of the mark. Results Marking with henna was clearly visible during all but one surgical procedure even after vigorous pre-operative skin preparation, thereby ensuring minimal use of fluoroscopy in henna-marked patients. The fading of the mark and use of fluoroscopy was significantly low in group A (p<0.05). There was no complication associated with marking with either marking method. Marks with henna disappeared on an average nine days later than with permanent marker. In terms of acceptability of mark, henna was preferred by almost all patients. Conclusions Henna paste is an ideal substance for use as a skin marker in conditions, such as foreign body removal, vertebral level identification, nail dynamization, marking tibial physis in children, and sequestrum in non-discharging osteomyelitis, and in marking blood vessel course in tumor surgery or in volar ganglion removal. Pre-operative skin marking with henna ensures minimal use of fluoroscopy, and it is particularly efficacious when ultrasound is used for localization as it can be directly applied over gel film.

Incidence, management and outcome assessment of post operative infection following single bundle and double bundle acl reconstruction.

INTRODUCTION: Post-operative infection is a dreadful complication of ACL reconstruction with gray zone over management guidelines. We aimed to establish commonest etiology, assess incidence of infection and effect on outcome, individually for single and double bundle ACL reconstruction techniques, so as to formulate appropriate management guidelines. METHODS: Our prospective study involved 1152 patients operated for ACL reconstruction (437- DBACL, 715- SBACL) from 2010-2013. Post-operative infection was diagnosed clinically supported by positive gram stain/ culture and increased cell count in knee aspirate. All patients were started on empirical antibiotics and arthroscopic lavage and debridement was done. Graft was retained if it was stable and intact. Data recorded at follow up was analysed statistically. RESULTS: In SBACL infection rate was 0.84% while in DBACL it was 2.52%. All patients with infection presented with pain, effusion, fever and increased WBC, ESR & CRP. Average time of presentation after the surgery was 2.27 weeks for DBACL and 2.16 weeks for SBACL. In both groups, S.aureus followed by S. epidermidis were commonest isolates. Patients were given IV antibiotics for 2 weeks and oral for further 4 weeks. DISCUSSION: Incidence of infection is higher with the double bundle technique, however, the functional outcome is not affected (p value 0.231). Joint aspirate is the gold standard diagnostic test for infection. CRP and ESR are the next dependable tests with high sensitivity but their specificity is low. A thorough debridement is necessary apart from recommended antibiotic cover of 2 weeks IV followed by 4 weeks oral antibiotics.

The scope of upper limb surgery for tetraplegics: Role of tendon transfers and Universal Cuff.

OBJECTIVE: The aim of this study was to evaluate the role of tendon transfers and universal cuff in restoring hand function in tetraplegic patients. METHODS: Twenty-one upper limbs on 12 tetraplegic patients (9 males and 3 females); mean age: 42.2 years (range 22-58 years) with a spinal cord injury at or distal to C6, were included in this study. Key pinch was restored using Brachioradialis to Flexor Pollicis Longus transfer and hook using Pronator Teres to Flexor Digitorum Profundus transfer. The gains achieved were measured objectively at six months and at final follow up, the average follow up being 26 months. The functional outcome was assessed using the Modified Lamb and Chan score. RESULTS: Average value was 1.67 kg for key pinch and 2.58 kg for hook grip at final follow up. The Modified Lamb and Chan score revealed good to fair outcome in 75% of patients. Complications resulted from stretching of transfer and mal-tensioning and were salvaged by the use of a 'Universal Cuff'. CONCLUSION: Surgery should be routinely offered to tetraplegic patients with deficient hand function in whom no recovery is expected after six months following spinal cord injury. Universal Cuff is a good salvage method for patients who refuse re-surgery. LEVEL OF EVIDENCE: Level IV, Therapeutic study.

A Rare Case of Glomus Tumor of the Great Toe: An Analysis of Behavior at This Rare Site.

UNLABELLED: Glomus tumor, originally known as an angioneuromyoma, is a benign neoplasm arising from specialized structures called glomus bodies, involved in thermoregulation. Although it has been reported at a number of sites in the body, this rare tumor is most commonly seen in the subungual areas of the digits of the hand. Only a handful of lesions have been reported in the toes. Because most foot conditions are treated by podiatrists and dermatologists, orthopaedic surgeons are generally unaccustomed to making early diagnoses. The purpose of this case report is to alert the attending surgeon regarding the possibility of glomus tumor as a cause of chronic toe pain. Also it has been observed that the behavior of this tumor varies with the site of occurrence-whether digital or extradigital. So we have extensively reviewed all similar reports in the literature to analyze the behavior of this tumor at this unusual location, apart from comparing it with the more common finger variety, to ensure it possibly is not a misclassification like the chemodectomas that were earlier thought to be glomus tumors. LEVELS OF EVIDENCE: Therapeutic Level IV: Case Study.

Clinical and radiological outcome after mini-open Latarjet technique with fixation of coracoid with Arthrex wedge mini-plate.

BACKGROUND: Technical faults leading to coracoid fractures during screw insertion and coracoid graft osteolysis are concerns with standard screw fixation techniques in Latarjet procedure. The purpose of this study is to share our experience using Arthrex wedge profile plate with mini-open technique for graft fixation, that ensures better load distribution between coracoid graft and glenoid. METHODS: We did retrospective analysis of 24 patients with recurrent anterior shoulder instability after failed arthroscopic Bankart's repair. Arthroscopic examination of affected shoulder was done in lateral position before making patient supine for open Latarjet. A low profile wedge plate (Arthrex) with two screws was used for the procedure. CT analysis was performed post-operatively at 6 months to see graft union and results were evaluated using the Rowe and Walch Duplay score. RESULTS: Mean follow-up time was 26 months. Postoperatively, mean forward elevation was 170.6 + 4.6° (loss of average 5.9°) and mean external rotation was 42.5 + 5.3° (loss of average 3.1°). All patients returned to their previous occupation. None reported to be having any recurrent subluxation. Functional assessment done using Rowe score and Walch Duplay score showed statistically significant improvement (p value 0.034). There were no implant-related complications and no case of coracoid graft osteolysis. CONCLUSIONS: Mini-open Latarjet with graft fixation with Arthrex mini-plate provides satisfactory outcome in patients who require reoperation due to dramatic bone loss and failed soft tissue reconstruction. The modified incision improves exposure enabling plate fixation and the secure fixation accelerates rehabilitation.

Humeral diaphyseal osteochondroma causing median nerve injury.

Osteochondromas are the most common benign tumours of the bone. They are solitary or multiple, pedunculated or sessile exophytic outgrowths from the bone surface that are composed of cortical and medullary component with an overlying hyaline cartilage cap. Marrow and cortical continuity with the underlying parent bone is the characteristic of the lesion; they mostly arise from the metaphysis of the bone. Osteochondromas arising from the diaphysis are rare; and nerve palsy arising in the setting of a diaphyseal osteochondroma is even rarer. This is a report of solitary osteochondroma arising from diaphysis of left humerus in a 10 years old boy, which resulted in median nerve palsy. Surgical excision relieved the symptoms completely. The aim of this case report was to draw attention to an unusual etiology of median nerve palsy caused by an osteochondroma arising from the diaphysis of humerus which is a rare site, and to emphasize its importance.

Ulnar styloid fracture in distal radius fractures managed with volar locking plates: to fix or not?

Distal radius fracture is usually associated with ulnar styloid fracture. Whether to fix the ulnar styloid or not remains a surgical dilemma as some surgeons believe that their repair is imperative while others feel that they should be managed conservatively. This prospective study involved 47 patients with unilateral fracture of the distal radius who met the inclusion criterion and underwent open reduction and internal fixation with volar locking plates; 28 patients (12 males and females = 16) had an associated ulnar styloid fracture (Group A) while 19 (7 males; 12 females) did not have any ulnar styloid fracture (Group B). At the time of final evaluation both the groups were compared clinically by measuring the grip strength and range of motion around the wrist and the radiologically by measuring radial angle, radial length, volar angle and ulnar variance. Subjective assessment was done using DASH score and final assessment using Demerit point system of Saito. In Group A, average time for consolidation was 9.4 weeks, 17 patients developed non-union of the ulnar styloid, average DASH scores was 4.4 and according to Demerit point system of Saito, there were 78.5 % excellent, 17.9 % good and 3.6 % fair results; there were 2 cases of loss of reduction out of which one had persistent ulnar sided wrist pain. In Group B the average time for consolidation was 10.2 weeks, average DASH score was 3.8.and Demerit point system of Saito yielded 78.9 % excellent, 15.8 % good and 5.3 % fair results. There was one case of loss of reduction and one case of carpal tunnel syndrome which was managed conservatively. Both groups attained excellent range of motion, grip strength and well maintained the post operative radiological parameters. The comparison of clinico-radiological parameters in both groups was found to be statistically insignificant. To conclude, ulnar styloid fracture or its non union does not affect the outcome of an adequately fixed distal end radius fracture. We urge caution in electing operative treatment of non-united fracture of the ulnar styloid until better scientific report for treatment of pain associated with these fracture is available.

Surgical rehabilitation of a tetraplegic hand: comparison of various methods of reconstructing an absent pinch and hook.

BACKGROUND: Since complete functional restoration after spinal cord injury may not always be possible, the major focus in such cases has to be on rehabilitation. We performed surgery in such patients to reconstruct important absent hand functions viz. pinch and hook using various methods described in literature and compared their outcome. METHODS: A total of 29 procedures were performed in ten patients (18 upper limbs) with tetraparesis consequent to cervical spine injury distal to C6 level who had at least grade 3 power of elbow extension but had not documented any significant improvement in hand function, at least 6 months post injury. Key pinch was reconstructed in 14 upper limbs using brachioradialis (BR) to flexor pollicis longus (FPL) transfer in 11 and pronator teres (PT) to FPL transfer in three limbs. Hook was reconstructed in 15 upper limbs: PT to flexor digitorum profundus (FDP) (n = 7), BR to FDP (n = 2), and FDP tenodesis (n = 6). The gains achieved were measured at intervals of 4 weeks, 3 months, and 6 months postoperatively and at a final possible follow-up of every patient, the average follow-up being 32 months. The functional outcome was assessed by the modified Lamb and Chan score. RESULTS: For key pinch reconstruction, both BR and PT turned to be equally efficacious donors, while for hook reconstruction, PT and BR transfer to FDP turned out to be superior to FDP tenodesis. The functional outcome as assessed by the modified Lamb and Chan score revealed good to fair outcome in 70 % of patients while poor in 30 %. Complications resulted from stretching of transfer, rupture of tenodesis, and maltensioning. CONCLUSION: Surgery can routinely be offered to suitable tetraplegics with deficient hand function in whom no useful recovery of any function is expected with at least 6 months elapsed post injury. Single-staged bilateral procedures enable maximal possible rehabilitation in minimal possible duration.

Early reimplantation for open total talar extrusion.

PURPOSE: To review outcome of early reimplantation for open total talar extrusion in 7 patients. METHODS: Medical records of 5 men and 2 women aged 19 to 53 years who underwent reimplantation for open total talar extrusion within 6 hours after road traffic accident (n= 6) or industrial injury (n=1) were reviewed. The talus was first irrigated with 9 to 10 litres of saline solution, followed by 10% povidone iodine. It was then reduced after thorough debridement and fixed with tension band wiring or external fixation. Ankle mobilisation exercises were started at week 6 and full weight bearing at week 14. Outcome was assessed using the American Foot And Ankle Society score. RESULTS: After a mean follow-up of 31.9 (range, 24-46) months, the mean American Foot and Ankle Society score was 81, and the mean dorsiflexion-plantar flexion arc was 36.9º (range, 25º-45º). All patients were able to walk with a balanced, unaided gait with mild-to-moderate pain (n=3) or pain-free (n=4). No patient developed deep infection or instability. Three patients developed avascular necrosis of the talus; restriction of motion was moderate at the ankle joint and severe at the subtalar joint. None of these 3 patients opted for revision surgery, as the pain was tolerable and did not limit their daily activities, but their condition was expected to deteriorate with time. CONCLUSION: Early reimplantation is recommended for open total talar extrusion, as it restores (to some extent) hind foot mechanics, heel height, and bone stock for activities of daily living and future reconstructive options.