Biofilms-What Should the Orthopedic Surgeon know?

Background: Musculoskeletal infections are a major source of morbidity for orthopedic and trauma patients, are associated with prolonged treatment times, and, unfortunately, suffer from poor functional outcomes. Further complicating the issue, antimicrobial resistance (AMR) is increasingly impacting the treatment of musculoskeletal infections with a diminishing repertoire of effective antibiotic agents for some highly resistant pathogens. Most orthopedic surgical procedures involve implants, and the formation of bacterial biofilms on these implants is now recognized as a major factor contributing to the failure of antibiotic therapy in orthopedic surgery. Methods: This review presents an overview of the types, structure, formation, and pathogenesis of biofilms as they pertain to musculoskeletal infections. Furthermore, it describes the key concepts in the management of biofilms and future perspectives for the better treatment of patients with biofilm-related musculoskeletal infections. Results: A bacterial biofilm is a dynamic, living conglomerate of bacteria encased in an extracapsular polysaccharide matrix (EPS). Biofilms are a natural mode of survival for virtually all bacterial species, including both Grampositive and Gram-negative bacteria, as well as fungi. The biofilm model of growth confers resistance by several well-defined mechanisms regardless of the species of the microorganism. In most cases, biofilm management often necessitates radical measures to ensure eradication including both surgical and medical interventions. Conclusions: Orthopedic surgeons should be aware of the key concepts pertaining to biofilms, and the impact that these can have on clinical practice.

A Cost-Effective Novel Surgical Technique of Core Decompression with Bone Marrow Aspiration Concentrate: A Preliminary Cadaveric Study.

Introduction: Core decompression supplemented by stem cell incorporation is an upcoming field of research in avascular necrosis of the femoral head. Plugging the canal to avoid loss of the concentrate injected has been recognized as a crucial step to improve the efficacy of the procedure. We describe a new surgical technique that results in native bone plug formation and eliminates the need for any additional blocker. Methodology: This pilot study was performed on 4 cadaveric proximal femurs. The standard technique was used for core decompression and bone marrow aspirate concentrate (BMAC) injection. Additionally, two more tracts were drilled, superolateral, and inferomedial to the primary tract. Results: No leakage of the radiopaque dye was observed from the entry point of the primary tract, ensuring its complete blockage in all 4 cadaveric proximal femurs. This was confirmed by sectioning the femur specimens which manifested bone plug formation at the confluence of the three tracts. Conclusion: Our technique is a unique and economical method of preventing leakage of BMAC through the entry point in the proximal femoral metaphysis. This may not only benefit patients but can also provide the groundwork for further research in this field.

The burden of post-traumatic amputations in a developing country - An epidemiological study from a level I trauma centre.

BACKGROUND: With the rapidly growing population and expanding vehicle density on the roads, there has been an upsurge in road accidents in developing countries. Knowledge about the causes and patterns of trauma-related amputations helps in the formulation of strategies for limb savage, timely management, and effective rehabilitation. OBJECTIVE: To study the epidemiology, demographic profile, and outcomes of post-trauma amputations at a level I tertiary care centre in North India. METHODS: Retrospective evaluation of the amputee data from 1st January 2018 to 31st December 2019, focusing on demographic details, injury mechanisms, surgical delays, hospital stay, and complications. RESULTS: A total of 17,445 trauma cases were seen in our trauma centre during the study period. Of these, 442 patients (2.5%) underwent major limb amputation. The hospital-based prevalence of traumatic limb amputation was 2.5%. The mean age of the amputees was 35.6years (range 1-75), and the majority were males (n = 369, 83.5%). The lower to upper limb involvement ratio was 3:1 (n = 338:105). A road traffic accident was the most common mode of injury (77.4%), followed by machine-cut injuries (16.1%). On-site traumatic amputation was seen in 23.1% (n = 102), while 43.5% had a mangled limb amputated in the hospital (mean MESS score 9.53). Overall, 27% of cases had a vascular injury after trauma, ultimately ending in limb amputation. The in-hospital mortality was 2% (n = 9/442). 43.7% of patients with a single limb amputation were discharged within 48 h. Extended hospital stay was noted in cases with associated fractures in the other limbs (28.5%), head or facial injury (9.9%), and with or without a combination of chest, abdomen, pelvic, or spine injury (7.2%). CONCLUSION: A 2.5% incidence of post-trauma amputation reflects on the severity of injury related to road and industrial accidents which predominantly affect the lower limbs at the peak of productive work life. In the absence of national amputation registries, the results underscore the need to focus on road safety protocols, patient transfer methods, and the up-gradation of local hospitals.

A Prospective Study Evaluating Factors Affecting Functional Outcome in Patients with Floating Elbow Injury.

BACKGROUND: Floating elbow injuries are complex injuries. Due to frequent association with severe soft tissue injuries and polytrauma, they have unpredictable functional outcome. This prospective study is aimed to evaluate the factors affecting functional outcome. METHODS: Thirty patients with floating elbow injuries were treated at a level 1 trauma center from July 2018 to June 2019 with minimum follow-up of 9 months. The outcome was assessed by disability for arm shoulder and hand score (DASH) and mayo elbow performance score (MEPS). RESULTS: The overall incidence was 16.09 per 1000, mostly caused by road traffic accidents and all cases were managed surgically. Age, gender, education, occupation, arm dominance, and mechanism of injury did not significantly affect the outcomes. Open fractures and patients requiring staged procedure were associated with poorer outcomes (p < 0.05); however, delay in surgery for more than 24 h significantly increased the rate of complications. There was no statistical difference in the proportion of patients who had nerve injury pre operatively and post operatively on the final outcome. CONCLUSION: Floating elbow injuries are relatively rare but nowadays the numbers are on the rise. Timely intervention with a multimodal approach and well-supervised rehabilitation can assure better final outcome.

Dual split and dislocation----a variant of Schatzker type-I tibial plateau fracture: A case report.

Schatzkter type-I tibial plateau fracture is a split fracture of the lateral tibial plateau in sagittal plane, consequent to valgus impaction caused by low velocity of trauma. However, a deep understanding of the different columns of the tibial plateau and patho-mechanisms of the injury led to the unmasking of atypical fractures around the tibial plateau. We have encountered 2 cases with unusual fracture pattern of the lateral tibial condyle caused by road traffic accidents. The fracture pattern and severity of injury deviate from the original description of Schatzker type 1; in view of dual plane split, there is rotation of the posterolateral column fragment along its sagittal plane plus grade-III medial collateral ligament injury. The patients were initially treated with knee spanning external fixator and after a latency of 5 days, definitive fracture specific fixation was done, combined with repair of grade-III medial collateral ligament injury. At the 6 months follow-up both the patients achieved satisfactory knee functions (knee society score case 1: 100 and case 2: 92) and returned to their jobs. The severity of fracture pattern and displacement as described should prompt for examination of associated ligament injury. Because of timely diagnosis, early and appropriate care promised an excellent function outcome even in such a severe nature of knee injury. To prompt the description of injury pattern we coined the name "dual split and dislocation" of lateral tibial plateau, as a complex injury variant of split fracture of lateral tibial plateau fracture.

Thermal imaging in total knee replacement and its relation with inflammation markers.

Total knee replacement is an end-stage surgical treatment of osteoarthritis patients to improve their quality of life. The study presents a thermal imaging-based approach to assess the recovery of operated-knees. The study focuses on the potential of thermal imaging for total knee replacement and its relation with clinical inflammatory markers. A total of 20 patients with bilateral knee replacement were included for thermal imaging and serology, where data was acquired on pre-operative day and five post-operative days. To quantify the inflammation, the temperature-based parameters (like mean differential temperature, relative percentage of raised temperature) were evaluated from thermal images, while the clinically proven inflammation markers were obtained from blood samples for clinical validation. Initially, the knee region was segmented by applying the automatic method, subsequently, the mean skin temperature was calculated and investigated for a statistical relevant relationship with inflammatory markers. After surgery, the mean skin temperature was first increased (>2.15 ℃ for different views) then settled to pre-operative level by 90th day. Consequently, the mean differential temperature showed a strong correlation with erythrocyte sedimentation rate (r > 0.893) and C-reactive protein (r > 0.955). Also, the visual profile and relative percentage of raised temperature showed promising results in quantifying the temperature changes both qualitatively and quantitatively. This study provides an automatic and non-invasive way of screening the patients for raised levels of skin temperature, which can be a sign of inflammation. Hence, the proposed temperature-based technique can help the clinicians for visual assessment of post-operative recovery of patients.

Role of supplemental teriparatide therapy in management of osteoporotic intertrochanteric femur fractures.

BACKGROUND: Despite the surgical advances, obtaining the desired outcome in osteoporotic intertrochanteric femur fractures is still a tough row to hoe for the surgeons. Consequently, the interest of the researchers has shifted towards establishing a holistic approach for managing such injuries. Teriparatide, a recombinant form of human parathyroid hormone, is a novel drug that has been proved to hasten fracture healing and in both animals and humans. We attempted to evaluate the influence of Teriparatide therapy in surgically fixed osteoporotic intertrochanteric femur fractures and provide the groundwork for further research in this area. METHODS: The results of osteoporotic patients who underwent only Proximal Femur Nailing [PFN] for intertrochanteric femur fractures were prospectively compared to the patients who received an additional Teriparatide therapy. We aimed to identify the effect of Teriparatide on the time to fracture union, bone mineral density [BMD], and other fracture related post-operative complications. The functional outcome was assessed using the Lower extremity functional scale [LEFS]. RESULTS: All patients were followed up for 6 months by which time all the fractures united. However, in the Teriparatide group, time to fracture union was shortened by about 2 weeks and improvement in BMD and functional outcome were significantly better. The rate of migration of the helical, varus collapse, and femoral shortening did not show any relevant difference. CONCLUSION: Our preliminary attempt shows that early union coupled with better functional improvement and a substantial increase in BMD tips the balance in favour of the Teriparatide therapy in osteoporotic patients with intertrochanteric femur fractures. Well-designed clinical trials conducted in a similar vein are further required to support our claim.

Application of 3D Printing in Hip and Knee Arthroplasty: A Narrative Review.

INTRODUCTION: Ideal surgical positioning and placement of implants during arthroplasty are crucial for long-term survival and optimal functional outcomes. Inadequate bone stock or defects, and anatomical variations can influence the outcomes. Three-dimensional printing (3DP) is an evolving technology that could provide patient-specific instrumentation and implants for arthroplasty, taking into account anatomical variations and defects. However, its application in this field is still not adequately studied and described. The present review was conceptualised to assess the practicality, the pros and cons and the current status of usage of 3DP in the field of hip and knee arthroplasties and joint reconstruction surgeries. METHODS: A PubMed database search was conducted and a total number of 135 hits were obtained, out of which only 30 articles were relevant. These 30 studies were assessed to obtain the qualitative evidence of the applicability and the current status of 3D printing in arthroplasty. RESULTS: Currently, 3DP is used for preoperative planning with 3D models, to assess bone defects and anatomy, to determine the appropriate cuts and to develop patient-specific instrumentation and implants (cages, liners, tibial base plates, femoral stem). Its models can be used for teaching and training young surgeons, as well as patient education regarding the surgical complexities. The outcomes of using customised instrumentations and implants have been promising and 3D printing can evolve into routine practice in the years to come. CONCLUSION: 3D printing in arthroplasty is an evolving field with promising results; however, current evidence is insufficient to determine significant advantages that can be termed cost effective and readily available.

Orthopedic Residency in a Tertiary Care Hospital of India: Positives, Negatives and Perspectives for Change.

BACKGROUND: Orthopaedic residency training is a 3-year period of preparation that converts a raw medical student into a proficient orthopaedic surgeon. Due to wide variations at different centers in India, the program in a tertiary hospital is presented, in an attempt to improve the overall levels of training. MATERIALS AND METHODS: PGIMER has produced many good surgeons who are well settled across the country and the world. A survey of the postgraduates of the last 30 years was done to highlight the perceptions about the program. An overview of the program was also added to the narrative to highlight the positive aspects of the training. RESULTS: 132 Orthopaedic passed-out residents from PGIMER could be contacted. 97% of them rated their residency experience as excellent or good, and stated that they would recommend this program to new residents. Key points highlighted by them were the readiness of trainees for any surgical contingency after graduation, continuation of the mindset for research, and their prompt acceptability into their subsequent places of work due to their place of graduation. DISCUSSION: Converting an orthopaedic resident into a competent surgeon involves knowledge upgrades and impartation of skills; these are not limited to the theory of orthopaedics, but involve the thought processes and the planning as a surgeon, the attitude towards patient management, and a continuously inquisitive scientific mind. The shortcomings and strengths of the residency program in PGIMER are discussed; international standard methodology limited to this institute like formal log books, mentorship program, hands-on skill development through courses, etc. is something that is recommended to be mandatory in all residency programs. CONCLUSION: The PGIMER Orthopaedic residency program could act as a basic model for other Indian medical schools, with any appropriate modifications. Standardization of Orthopaedic residency programs could allow upgrading to International levels.

Prominent Resident's Ridge as a Potential Cause of Anterior Cruciate Ligament Impingement: A Case Report.

BACKGROUND: The resident's ridge is an arthroscopic landmark that is consistent with the anterior border of the anterior cruciate ligament (ACL) femoral attachment. The identification of the landmark allows for accurate graft placement. CASE REPORT: We report a case of a 30-year athletic individual with an ACL-deficient knee, who had an abnormally large resident's ridge, abutting the midsubstance of the torn ACL; the residual femoral attachment was behind the ridge. Resection and burring of this ridge were needed to expose the posterior aspect of the intercondylar notch; even after bone-patellar tendon-bone graft placement, some additional removal of bone had to be done to reduce graft impingement on this area in extension. CONCLUSION: Abnormal resident's ridge may be misleading about the anatomy of the lateral femoral condyle area. Appropriate resection of abnormal bone is the key to the identification of femoral footprint and graft placement. We speculate that this bony projection may even have contributed to the ACL injury, and extra bone had to be removed to minimize subsequent impingement.

Patient profiles of below knee-amputation following road traffic accidents - An observational study from a level 1 trauma centre in India.

BACKGROUND: Primary amputation below the level of the knee joint is the most frequently performed amputation following trauma; however, data about incidence, patient profiling, and causative factors are seldom available in India. OBJECTIVE: To evaluate the profile and incidence of trauma-related amputations below the level of the knee joint at a level 1 trauma center. METHODS: An observational study over six months was conducted at a level 1 trauma center of north India. Epidemiological data such as age, sex, occupation, socioeconomic status, mechanism of injury, time of surgery, single or staged procedure, and complications were recorded from the admission files. OBSERVATIONS: 125/3047 (4.1%) trauma patients underwent amputation, of which 32.8% (41 of 125) had amputation below the level of the knee joint. Unilateral transtibial amputation was the most common (85.3%) involving 40/41 males with a mean age of 37.2 years of low socioeconomic status. Road traffic accidents were the most common cause (85.36% of cases). 39 of 41 cases presented within 24 h of injury and underwent surgery within 24 h of presentation. Secondary surgery was needed in 24.4% of the patients and revision amputation was done in only 2.4% (n = 1/41). No patient developed medical complications, and the average hospital stay was 8.7 days with a range from 2 to 14 days. CONCLUSION: We have documented a significant amputation rate in trauma cases (4.1%) reflecting on the seriousness of patients seen at our center. Most patients are young males at the peak of their productive lives, and from low socioeconomic status. Road Safety is essential, and specialized services for the amputees may be the need of the hour.

Modified cerclage wiring in comminuted transolecranon fracture-dislocations of the elbow.

Transolecranon fracture-dislocations are a result of high-energy trauma, caused due to axial loading of the flexed forearm, with associated anterior dislocation of the ulna with respect to the distal humerus. The usual management of these comminuted and unstable fractures is by using locking compression plates via the dorsal approach. However, plating in cases of poor soft tissue coverage and open wounds can be precarious. In this study, we aimed to evaluate outcomes of cerclage wiring in the management of comminuted trans-olecranon fracture-dislocations in such scenario. A total of seven patients diagnosed with trans-olecranon fracture-dislocation with poor soft tissue coverage who underwent cerclage wiring were included in the study. The aim was to realign the proximal portion of the olecranon to the trochlea and restore the normal ulnohumeral articular relationships accomplished by the anatomical reconstruction of the greater sigmoid notch. Reconstruction of the proximal ulna was started from the distal to the proximal direction so as to convert an unstable fracture into a stable one. After the reduction of the proximal fragment, two long 2 mm K wires were inserted from the tip of the olecranon into the intramedullary canal (with at least 1 wire passed subchondrally), and later cerclage was done. Postoperatively the patient was immobilized for a duration of two weeks and was later started on active assisted mobilization of the elbow. All patients showed fair-to-excellent outcome on the Mayo elbow performance score (MEPS) at the final follow-up (five patients had an excellent score, one had a good score, and one had a fair score). At the final follow-up, the mean extension, flexion, pronation and supination were -20, 117.14, 82.85 and 78.57 degrees respectively. The key components of such management are the restoration of articular congruity, including continuity of the sigmoid cavity, ulnar length, and early initiation of active elbow movements to avoid joint stiffness. Optimal functional results can be achieved with K wire and cerclage when a stable anatomic reconstruction is accomplished, as a feasible alternative to plating.

Functional Outcome of Surgically Treated Isolated Coronoid Fractures With Elbow Dislocation in Young and Active Patients.

Coronoid fractures are less frequent injuries seen in around one-tenth of patients with elbow dislocation. Any injury to the coronoid process can be associated with elbow instability, in which injury to collateral ligaments co-exists, resulting in a loss of congruency of the elbow joint. However, there is a scarcity of evidence regarding patients' management with elbow dislocation and associated coronoid fractures. So, our aim is to assess the functional outcome of the elbow after operative fixation in patients with any type of coronoid fracture with associated elbow dislocation. A total of six patients with closed coronoid fracture of the elbow, with associated elbow dislocation, without any other associated trauma or previous surgery to the same limb, were included in our study. After closed reduction, patients with an incongruent reduction of the elbow joint were operated. The injured structures were repaired in an inside-out sequence: the coronoid fragment was first reduced by using a lasso-type suture. The larger fragments of the coronoid were fixed with either a screw or a plate when deemed necessary. Then, the lateral collateral ligament was repaired either using a suture anchor or transosseous (No. 2 Arthrex; Naples, Florida) sutures. After repair, the elbow was examined for stability radiologically using the hanging arm test; a concentric reduction of the elbow in lateral view during this test indicates a stable elbow. All patients showed a good to excellent outcome on the Mayo elbow performance score (MEPS) at the final follow-up (three patients had an excellent score while three had a good score). At the final follow-up, mean elbow flexion was 124º, loss of extension was 10º in only one patient, mean supination was 80º, and mean pronation was 72º. Isolated fractures of the coronoid associated with elbow dislocation require appropriate evaluation and management. Closed reduction and immobilization alone in young and active patients may not be sufficient, especially in patients with incongruent ulnohumeral joint. Surgical fixation of the coronoid fragment and repair of the collateral ligament, whenever indicated, can provide good functional outcomes.

Bilateral Quadriceps Rupture in an Elite Weight Lifter: A Case Report and Review of Literature.

Simultaneous bilateral quadriceps tendon ruptures (QTR) are rare injuries in sportspersons; weightlifting, involving sudden eccentric contraction of the bilateral quadriceps, has the potential to cause this injury. We present a case of an elite weightlifter with bilateral quadriceps tear occurring during the "jerk" part of clean and jerk phase of weightlifting; single stage bilateral end to end repair was done, followed by 3 weeks of cast immobilisation. He then underwent a supervised rehabilitation protocol, leading to graduated strengthening of the muscles. He went back to competitive sport after 2 years and participated in a national championship after 5 years. Detailed questioning revealed a history of anabolic steroid use in the early phase of his career; a literature review showed only seven cases of this injury pattern in weightlifting/bodybuilding sports, and five of these seven had a definitive history of anabolic steroid use. Bilateral QTR may be a pointer to predisposing factors like use of steroids, which should be diligently identified. Good outcomes are possible after early surgical repair and rehabilitation, with high rates of return to sports.

Non-union lateral femoral condyle Hoffa fracture: a case report.

An isolated Hoffa fracture of either of the femoral condyle is infrequently encountered. Owing to its rarity, it is often missed and subsequently results in non-union. The knowledge of its surgical management comes from the sporadically reported cases in the literature. The most preferred approach is parapatellar, providing adequate exposure of the fracture and the joint surface. We report a case of non-union of Letteneur-2C lateral condyle Hoffa fracture of the left distal femur in a young adult as a result of missed bony injury. Surgical fixation was done using a posterolateral approach to the knee and fixing the fracture with headless compression screws placed posteroanteriorly. After about 1 year of follow up, patient demonstrated excellent functional outcome in the form of a pain free mobilisation and near normal range of motion. We emphasise the fact that the importance of vigilance while diagnosing fractures of distal femur cannot be stressed enough and with proper surgical management and rehabilitation, desirable results can be achieved.