Duloxetine as an Analgesic in Patients Who Do Not Have Central Sensitivity Undergoing Single-Setting, Bilateral Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized, Placebo-Controlled Trial.

BACKGROUND: Pain control and patient satisfaction after total knee arthroplasty (TKA) have room for improvement. While studies have reported better analgesic outcomes with antidepressants like duloxetine in patients who do not have central sensitivity (CS), we undertook this trial to determine the short and midterm analgesic role of low-dose duloxetine in patients who do not have CS. METHODS: This prospective, double-blinded, randomized, placebo-controlled trial was conducted in 106 patients undergoing single-setting, bilateral TKA under spinal anesthesia. There were 2 matched groups, with one given 20 mg of duloxetine and the other given a placebo (similar in appearance and weight) from preoperative day 2 to postoperative day 28. Follow-ups were scheduled at 48-hours, 1-week, 2-weeks, 4-weeks, and 3-months. Pain was measured using a visual analogue scale at rest and visual analogue scale at mobilization (mVAS). Secondary measures included additional non-steroidal anti-inflammatory drug consumption, patient satisfaction, and safety profile. RESULTS: The visual analogue scale at rest in the duloxetine group was better in the first 48 hours (6.38 ± 1.32 versus 7.02 ± 0.99; P = .017), 1-week (4.76 ± 1.24 versus 5.89 ± 1.06; P < .001), and 2-weeks (3.34 ± 1.19 versus 4.26 ± 1.02; P < .001) follow-up. The mVAS remained significantly higher in the duloxetine group in the first 48 hours (7.23 ± 1.12 versus 8.21 ± 0.69; P < .001), 1-week (5.83 ± 1.11 versus 6.82 ± 0.92; P < .001), and 2 weeks (3.70 ± 0.89 versus 4.60 ± 1.03; P < .001) follow-up. Both outcomes became comparable from 4-week follow-up onward. Patient satisfaction (8.44 ± 1.68 versus 7.17 ± 1.04; P < .001) and additional non-steroidal anti-inflammatory drug consumption (2,770 ± 533.05 versus 3,566.04 ± 464.54; P < .001) were better in the duloxetine group, with a comparable safety profile. CONCLUSIONS: In patients who did not have CS, persistent pain after bilateral TKA can be managed safely and successfully by a daily dose of 20 mg Duloxetine, improving patient satisfaction and analgesic consumption in the acute postoperative phase.

Role of concomitant percutaneous pie crusting and local corticosteroid injection in lateral epicondylitis: a prospective, case control study.

BACKGROUND: Lateral epicondylitis is an increasingly debilitating condition in working population. Evidence for conservative treatment modalities has been inconclusive. Percutaneous pie crusting of the common extensor origin at the lateral epicondyle at the time of local corticosteroid injection (CSI) has been proposed sparsely. The objective of this study was to analyze if concomitant CSI and pie-crusting of the common extensor origin provides better outcome than CSI alone in lateral epicondylitis. METHODS: This case-control study on 236 patients was conducted at a single center between January 1, 2020, and May 31, 2022. Patients were divided into two groups (n=118 each) based on their preference. Group A underwent CSI alone and group B underwent pie crusting along with CSI. The clinical and functional outcomes of all patients were evaluated at 2, 4, 6, and 12-week post-procedure using the visual analog scale (VAS) and Nirschl score. The mean time for return to daily activities was also compared. RESULTS: Both groups showed significant improvement in post-procedure outcome at successive follow-ups on intragroup longitudinal analysis (VAS: F=558.384 vs. F=1,529.618, Nirschl: F=791.468 vs. F=1,284.951). On intergroup analysis, VAS of group B was superior to that of group A; however, it was statistically significant (P<0.05) only from the 6-week follow-up onwards. Nirschl score of group B was significantly better throughout the period of follow-up (P<0.05). Group B returned to daily activities faster than Group A (6.2±0.44 weeks vs. 7.18±0.76 weeks). CONCLUSIONS: Concomitant pie crusting with CSI is recommended for lateral epicondylitis as it provides significantly better results than CSI alone.

Delayed Recovery of Idiopathic Common Peroneal Nerve Palsy After Total Knee Arthroplasty: A Rare Case Report.

Introduction: Common peroneal nerve palsy (CPNP) is a rare complication post total knee arthroplasty (TKA). Even though it is diagnosed acutely, the recovery potential is just over 50%. The average period for complete recovery in such cases is 5 months; however, the management remains controversial. Through this report, we present one such case of left sided complete CPNP after bilateral TKA who was conserved with various modalities. Even though the recovery was delayed, the patient made full recovery. Case Report: A 70-year-old female patient was diagnosed to have bilateral tricompartmental knee osteoarthritis with varus deformity, both clinically and radiologically (Kellgren-Lawrence grade 4). She underwent bilateral TKA in a single sitting as per the standard protocols practiced by the primary author. On post-operative day 1, she had left-sided foot drop with a complete sensory deficit. The patient underwent routine rehabilitation with an ankle foot orthosis splint in the immediate post-operative period, with simultaneous faradic current stimulation for the left lower limb. Periodic electromyography and nerve conduction study was done at the end of 4-week and 3-month post-TKA. At 6.5-month post-surgery, she made a full clinical recovery. Conclusion: The surgical maneuvers and full neurovascular examination before and after every TKA surgery should be carefully performed. Despite this, if a patient presents with CPNP, the surgeon need not take an aggressive approach, unlike fracture fixation cases. These patients can be managed conservatively using appropriate orthosis, physical therapy, and faradic current stimulation. Through this case, we attempt to report that CPNP patient can recover even after 6 months of surgery when there is no tangible cause for the palsy.

Effects of glenohumeral corticosteroid injection on stiffness following arthroscopic rotator cuff repair: a prospective, multicentric, case-control study with 18-month follow-up.

BACKGROUND: This study aimed to analyze the efficacy of single-dose corticosteroid injection (CSI) administered at 6 weeks postoperative to treat stiffness following arthroscopic rotator cuff repair (ARCR). METHODS: In this prospective, multicentric, case-control study, post-ARCR stiffness at 6 weeks was treated with either a single dose of intra-articular CSI (CSI group) or physical therapy with oral analgesics (non-CSI group). Pain intensity according to visual analog scale (VAS), functional outcome using the Constant Murley Shoulder Score, time to return to activities of daily living (ADLs), and retear rate were recorded at 6 weeks, 9 weeks, 12 weeks, 6 months, 12 months, and 18 months postoperatively in both groups. RESULTS: A total of 149 patients (54.5%) in the CSI group and 124 patients (45.5%) in the non-CSI group were included in this study. Pain and function were significantly better in the CSI group at 9-week, 12-week, and 6-month (P<0.001) follow-up, whereas they were not significantly different when the groups were compared at 12- and 18-month follow-up. The mean duration to return to ADLs was significantly shorter (P<0.001) in the CSI group. The incidence of retears was not significantly different (P=0.36) between groups at the end of 18 months of follow-up. CONCLUSIONS: Single-dose intra-articular CSI administered at 6 weeks postoperative to treat post-ARCR stiffness significantly improved pain, function, and duration of return to ADLs without increasing the risk of retears compared to patients who did not receive intra-articular CSI.

Retention Stitches: A Concept of Wound Closure of Knee Arthroplasty in Obese Patients.

Background: Knee joint arthroplasty is a commonly performed procedure. However, number of obese patients undergoing total knee arthroplasty is on a rise. In such cases, post closure using routine techniques, there have been an increasing number of cases of wound dehiscence and complications like persistent discharge and delayed healing. To overcome this problem, the author has come up with an innovative technique in closure. Materials and Methods: 27 patients, who were obese, were included in the study and operated at Orthopaedic Arthroscopic Knee and Shoulder clinic. The patients were evaluated pre operatively clinically and planned for retention stitches for closure. Same technique was followed for closure in all the patients. Suture removal was done at 2 weeks and patients were followed up for a period of 6 months for any complications. Results: In 27 patients undergoing retention stitches post total knee arthroplasty, patients were followed up for a mean period of 14 months, with minimum being 6 months and maximum being 5 years. Patients showed no complications such as wound dehiscence, discharge, localised skin necrosis or cut-through of stitches. Conclusion: Retention stitches in knee arthroplasty is an innovative, ideal, yet easily replicable method of wound closure in obese patients, especially with BMI > 30 (Obesity grade 1 or more). Patients undergo better and uneventful wound healing, which is of paramount importance in a surgery like this. In all these patients, the rehabilitation post surgery is also similar to the other patients, hence not affecting the outcome. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-021-00596-y.

Functional Outcome after Repair of a Post-Total Knee Replacement Quadriceps Rupture in a Morbidly Obese Patient: A Rare Case Report.

Introduction: Quadriceps rupture after a total knee arthroplasty is a rare complication. In addition, morbid obesity confounds the early diagnosis of any loss of function of the extensor mechanism. Poor tendon quality, fraying, and retraction of the tendon pose a distinctive challenge while repair, predisposing it to failure. The literature is devoid of reports highlighting this complication in a morbidly obese patient and its subsequent successful management. Case Report: Through this case, we report a morbidly obese 71-year-old who underwent an uneventful left sided total knee arthroplasty and suffered from an atraumatic quadriceps rupture on post-operative day 17. The diagnosis was confirmed on ultrasound followed by magnetic resonance imaging. An innovative technique of repair incorporating two, 5 mm suture anchors for fixing the ruptured quadriceps into the patella, and subsequent fortification of the repair was undertaken, followed by a guarded physiotherapy regimen. At 10 weeks post-repair, the patient started walking without any assistive device and achieved excellent clinical and functional outcome without any complications. Conclusion: Post-total knee arthroplasty quadriceps rupture is a rare but dangerous complication, even more so in a morbidly obese patient due to the inherent weakness of the muscles and tendons. Timely diagnosis and adequate repair using the innovative technique described in this study, along with a guarded physiotherapy regimen that can help in dealing with such complications successfully, as shown in this case.

Role of debulking mucoid ACL in unicompartmental knee arthroplasty: a prospective multicentric study.

BACKGROUND: Mucoid degeneration of the anterior cruciate ligament (ACL) has been shown to cause restricted terminal range of motion and rest pain. If present in a patient undergoing unicompartmental knee arthroplasty, it can deteriorate the final outcome. This study aims to compare functional and clinical outcomes of debulking the mucoid ACL in patients undergoing mobile-bearing unicompartmental knee arthroplasty (UKA). METHODS: Patients with mucoid ACL undergoing mobile-bearing UKA at five different centres by five different arthroplasty surgeons were included. They were segregated into two groups matched for all demographic and pre-operative values: group A did not undergo debulking; group B underwent open debulking by a 15-number blade prior to UKA. Patient-related outcome measures, rest pain, clinical outcomes, and subjective patient satisfaction were recorded and compared at 2 years follow-up. RESULTS: A total of 442 patients (226 patients underwent debulking, 216 patients did not undergo debulking) were included. Both groups showed overall improvement after surgery, however, patients who underwent debulking performed better at 2 years follow-up in terms of Knee Society functional score, International Knee Documentation Committee scores, range of motion, rest pain and overall patient satisfaction (p < 0.05) as compared with their counterparts. CONCLUSIONS: Debulking of mucoid ACL in patients undergoing unicompartmental knee arthroplasty significantly reduces the rest pain and improves the final range of motion of the knee joint, subsequently improving the overall functional and clinical outcome of the patient and resulting in greater patient satisfaction.

Underestimation of a Giant Lipoma on Magnetic Resonance Imaging: A Rare Case Report.

Introduction: Lipomas are the most common benign mesenchymal tumor. The solitary subcutaneous lipoma accounts for approximately onequarter to one-half of all soft-tissue tumors. Giant lipomas involving the upper extremities are rare tumors. This case report presents a subcutaneous giant lipoma in the upper arm weighing 350 g. Due to its long-term presence, the lipoma caused discomfort and pressure effects in the arm. Gross underestimation on magnetic resonance imaging (MRI) made its removal challenging and difficult. Case Report: Through this case, we report a 64-year-old female who consulted us in the clinic with complaints of discomfort, feeling of heaviness, and a mass in the right arm since 5 years. On clinical examination, there was asymmetry in her arms with her right upper arm showing a visible swelling (8 cm × 6 cm) over its posterolateral aspect. On palpation, the mass was soft, boggy, not attached to the underlying bone or muscle, and not involving the skin. A provisional diagnosis of lipoma was made and the patient was asked to undergo plain and contrastenhanced MRI for the confirmation of the diagnosis, the extent of the lesion, and infiltration into the surrounding soft tissue. The MRI revealed a lobulated deep lipoma in the subcutaneous plane with pressure effects over the posterior fibers of the deltoid muscle. Surgical excision of the lipoma was carried out. The cavity was closed using retention stitches to prevent the formation of a seroma or hematoma. Complaints of pain, weakness, heaviness, and discomfort completely subsided by the 1st month follow-up. The patient was then followed up every 3 months for 1 year. No complication or recurrence was noted throughout this period of time. Conclusion: The extent of lipomas can be underestimated on radiological imaging. It is common to find a bigger lesion than reported and to plan and execute the incision and surgical approach accordingly. Blunt dissection should be preferred when there are chances of neurovascular involvement or injury.

Functional and clinical outcome of anterior cruciate ligament reconstruction with peroneus longus autograft and correlation with MRI after 3 years.

Introduction: Autograft options for anterior cruciate ligament reconstruction over the years have gone from bone-patellar tendon-bone to hamstring to peroneus longus tendon. Considering the drawbacks of other autografts, we analyse peroneus longus autograft holistically as a viable alternative. Materials and methods: This was a prospective study of 113 patients undergoing anterior cruciate ligament reconstruction with peroneus longus autograft between January 2017 and November 2018 for isolated, full-thickness ACL tears. Functional analysis was done using the Tegner-Lysholm score pre-operatively, at 6 months, 1 year, 2 years, and 3 years postoperatively. At terminal follow-up, stability was checked clinically by Lachman test, residual morbidity of donor site was assessed using foot and ankle disability index, and radiographic correlation was done with magnetic resonance imaging. Results: The mean diameter of the graft after tripling was 9 ± 0.71 mm and the average length before tripling was found to be 27.07 ± 2.76 cms. At terminal follow-up, 101 patients showed excellent, while 12 patients showed good outcomes. The mean foot and ankle disability index was 94.8 ± 3. 90.27% of patients had no laxity on clinical examination, and magnetic resonance imaging of all the patients at terminal follow-up showed good graft uptake. Conclusions: Peroneus longus autograft shows intraoperative consistency and gives excellent functional outcome, clinical stability, and no donor site morbidity even three years postoperatively.

Pseudoaneurysm of the Lateral Genicular Artery Following Unicompartmental knee Arthroplasty: A Rare Case Report.

Introduction: Unicondylar knee replacement is a minimally invasive technique of surface replacement of the knee joint. Very little literature is available regarding vascular complications in patients who undergo this procedure due to their extremely rare nature. Case Report: This first-of-its-kind report describes a case of pseudoaneurysm of the lateral genicular artery of the right knee in a hypertensive, 65-year-old man, following a single sitting bilateral unicompartmental knee replacement (UKR). With no involvement of the lateral compartment in UKR, we suspect an underlying mechanical element as the cause of the pseudoaneurysm. Patient presented with swelling and pain in the right knee for the first time at 8-month postoperatively, and after aspiration of the hemarthrosis, had two events of recurrence with increasing frequency. Dynamic magnetic resonance angiography confirmed the diagnosis and the patient underwent angiography-guided embolization of the lateral genicular artery using polyvinyl alcohol particles, with no recurrence in over a year since then. Conclusion: Pseudoaneurysm of the lateral genicular artery is a possible cause of recurrent hemarthrosis even after unicondylar knee replacement and requires a high degree of suspicion for its timely diagnosis and management.

Management of a Rare Case of Cavernous Medullary Intraosseous Hemangioma in Proximal Tibia of a 38-year-old Female.

Introduction: Intraosseous hemangiomas (IH) are one of the rarest bone tumors that an orthopedic surgeon comes across, more so in the long bones. It most often affects adult females, severely blunting their activities of daily living, coupled with potential debilitating complications such as pathological fracture. Case Presentation: We present a case of a 38-year-old female who presented with long standing pain and swelling in the left knee. Radiology, in the form of plain radiographs and magnetic resonance imaging, narrowed the diagnosis down to a benign form of osteoblastoma or hemangioma. With this in mind, the patient underwent radical excision of the lytic lesion, along with a margin of the surrounding normal bone. The defect was filled with impaction bone grafting and supplemented by a hydroxyapatite block and a poly ethyl ether ketone plate. The patient had excellent clinical, functional, and radiological outcomes at 6 months follow-up. Conclusion: With the inherent rarity of IH, especially when it affects the long bones, it has barely been reported in orthopedic literature. Subsequently, management protocols for such lesions are ill-defined, which can be deleterious to the patient as well as the surgeon. Through this case report, we show how to approach a patient presenting with associated complaints, and show a detailed outline of an efficacious management regime that gave excellent outcomes in our patient.

Allograft Impaction and Supplementary Plating for the Management of Epi-Metaphyseal Enchondroma: A Rare Case Report.

Introduction: Enchondroma is a common bone tumor; however, its location in the proximal epi-metaphyseal region of the tibia is a rare finding. Its management is complicated by the weight-bearing nature of the site and despite an array of available treatment modalities in the literature, there is no fixed consensus. Case Report: Through this case, we report a 60-year-old female who was evaluated for bilateral knee osteoarthritis. On plain radiography, a lytic lesion was noted which on CT guided biopsy was confirmed to be an enchondroma of the right proximal tibia. The patient underwent extensive curettage, allograft impaction, and supplementary fixation by a poly ethyl ether ketone plate. Following a period of immobilization, she was able to walk full weight-bearing after 3 weeks of the surgery and carry out her daily activities at 2 months. At 1 year postoperatively, the patient achieved excellent clinical, radiological, and functional outcomes without any complications. Conclusion: Management of an enchondroma in weight-bearing regions of long bones can pose multiple challenges. Timely diagnosis and management by thorough curettage, uncompromised allograft impaction, and supplementary fixation by a PEEK plate give excellent short-term and long-term results.

Management of a Displaced Pathological Fracture in the Proximal Humerus of a Patient with Autism Spectrum Disorder: A Rare Case Report.

Introduction: Pathological fractures in pediatric age group are most commonly secondary to bone tumors. Management of such cases in patients with autism spectrum disorder (ASD) is complicated by the prevalence of low bone mineral density (BMD) in these patients. Case Report: Through this case, we report a 13-year-old male diagnosed with autism spectrum disease, who was brought by his parents with a history of trivial trauma and gross deformity of the left humerus. On plain radiography, a displaced fracture in the foreground of a lytic, cystic lesion was noted which on magnetic resonance imaging was confirmed to be metadiaphyseal unicameral bone cyst. The patient underwent extensive curettage, allograft impaction, and definitive fixation by a locking compression plate. Following a relatively extended period of immobilization, he was started on range of motion exercises followed by strengthening. He was able to return to his pre-operative activity levels at 14 weeks postoperatively. At 1-year postoperatively, the patient achieved excellent clinical and radiological outcomes, without any signs of failure, complications, or signs of recurrence. Conclusion: Management of pathological fractures in pediatric patients with ASD can be challenging due to the associated low BMD and potential non-compliance from the patient's end. Such cases are best treated with open curettage, allograft impaction, and definitive fixation by locking compression plate, even if present in a non-weight bearing bone.

Lesser Tuberosity Avulsion Fracture: A Rare Case Report.

Introduction: Lesser tuberosity avulsion fractures are rare and often missed. Patients often complain only of heaviness around the shoulder and some loss in range of motion. Case Report: This is a rare case of a lesser tuberosity avulsion fracture with displacement. The patient was a 29-year-old male who suffered an injury to the right shoulder due to a fall. Post-fall, the patient developed typical heaviness and restrictions in the range of motion of his right shoulder. Radiographs initially taken were not true anteroposterior (AP) views. The fracture was primarily missed by another surgeon, after which on opting for a true AP radiographs, the fracture was diagnosed. The fracture was managed by an open deltopectoral approach. Fracture fragment was reduced to its footprint and was fixed using 2 × 4.0 mm cancellous screws. Post-surgery, the patient was advised 3 weeks of immobilization after which mobilization was started. By monitored physiotherapy, consistent results can be obtained without loss of reduction. In this case too, full ranges with strength were achieved by 3 months postoperatively. Conclusion: Such fractures often missed may cause loss of external rotation movements in the patient and eventually malunion of the fragment if displaced. Watchfulness and timely management of the fractures can give excellent results. This case report aims at increasing the awareness among the budding shoulder surgeons in identifying such injuries at the earliest, and the means of managing them.

The Black Knee - A Case Report.

INTRODUCTION: Ochronotic arthropathy in patients with alkaptonuria is a rare hereditary disorder. The altered metabolism causes the homogentesic acid derivatives to deposit in various connective tissues causing characteristic pigmentation. Due to the close clinical resemblance to that of a degenerative disorder, diagnosis of ochronotic arthropathy usually occurs intraoperatively. We report arthroscopic findings of a 50-year-old female with ochronotic arthropathy. CASE REPORT: A 50-year-old woman came with complaints of pain and swelling in the left knee. Clinical examination and MRI findings were correlated to reveal a tear of lateral meniscus. On arthroscopic examination, the blackish pigmentation of the meniscus and the articular cartilage led to the diagnosis of ochronotic arthropathy. CONCLUSION: Arthroscopy plays an important role in diagnosis and treatment of patients with ochronotic arthropathy. The characteristic arthroscopic finding may aid diagnosis even in patients who do not have other systemic manifestations. Timely arthroscopic intervention can help delay the disease progression.

Modified Technique for Patellar Tendon Repair Post-Total Knee Arthroplasty: A Case Report.

INTRODUCTION: Rupture of patellar tendon following total knee arthroplasty (TKA) is a rare but disabling complication. Results of the primary repair of the patellar tendon after the TKA are associated with higher complication rates and a poor outcome. We report a rare case of traumatic patellar rupture, 5 years after the TKA managed using a primary repair with good post-operative outcome. CASE REPORT: A 75-year-old female was operated for sequential bilateral Grade 4 osteoarthritis. Five years after the left-sided TKA, she sustained a fall while coming down the stairs and avulsed her patellar tendon on the left side. The management in our case was done by primary repair using two techniques with augmentation using autologous semitendinosus free graft. CONCLUSION: Management of a patellar tendon rupture/avulsion after TKA is unpredictable and associated with poor functional outcomes. Various methods have been described with inconsistent clinical evidences. The operating surgeon must consider the potential advantages and disadvantages of these techniques.

Huge Subchondral Cyst Communicating with Medulary Canal of Femur in OA Knee-Treated by Extension Stem and Bone Grafting.

INTRODUCTION: We report an osteoarthritic patient with huge sub-chondral cyst-like lesions in the Anterior part of distal femur. Deep and large bone defects and severe lateral laxity due to Advanced osteoarthritis was successfully treated with semi-constrained type total knee arthroplasty with long stem. CASE REPORT: A 70yrs old Female was admitted in our institution diagnosed with severe bilateral Osteoarthritis. The x-rays showed bone on bone Tricompartment OA Knee with Varus Malalignment. She was posted for Single Stage Bilateral Total Knee Replacement and as planned the Left Knee Was Operated first. After exposure, Proximal Tibial, Distal Femoral Cuts and measurement of extension gaps the synovium from the anterior Femur was removed and sizing was done. The AP cut was then proceeded with. We spotted a small Osteochondral Cyst in the Anterior Femur which was curretted to remove the cystic material, which is when we realised that the cyst was large and communicating with the medulary canal. The remaining Femoral preparations was done keeping in mind the risk of iatrogenic fracture and extension Stem was used in the femur. The defect was then packed cancellous bone graft. CONCLUSION: If suspected a Preoperative MRI should be done to exclude any sub-chondral cysts osteochondral defects and any surprise during surgery. Usually one should keep extension stems ready for difficult cases. Operating surgeon should know his implants very well, as in many standard implants extension stems can only be used when distal femur cuts are taken accordingly as 5° Valgus. Mini incision should be avoided because it may fail to reveal such surprises and may land into periprosthetic fractures.