Incidence and effectiveness of manipulation under anaesthesia for stiffness following primary total knee arthroplasty.

Background: There are various modalities of cor- rection of stiffness following total knee arthro-plasty. Manipulation under anaesthesia (MUA) is generally indicated for people who fail to achieve their pre operative range of motion at 12 weeks. The purpose of this study was to determine: (1) the effect of MUA on Flexion arc (2) the influence of timing of MUA from index procedure and of diabetes mellitus on final flexion achieved. Methods: We retrospectively evaluated patients who underwent manipulation following total knee arthroplasty at our institution between January 2016 to December 2018. For the purpose of analysis, we have divided the patients into two groups. Those who underwent manipulation within 12 weeks and later than 12 weeks. We have also compared the effect of MUA between diabetic and non-diabetic patients. All were operated with posterior stabilised (PS) prosthesis by a single senior arthroplasty surgeon. The final flexion achieved during their last clinical follow-up were recorded and compared with the pre MUA flexion. Results: The incidence of MUA after TKA at our institute during this period is about 1.14 %. There was a significant statistical difference between the pre and post manipulation flexion, with p value <0.01. There was no significant statistical difference between those who were manipulated before 12 weeks and after 12 weeks in improving the Flexion of the operated knees. We have found that both the diabetic and non diabetic group had comparable flexion after the manipulation in our study. Conclusion: Manipulation after anaesthesia is a safe first intervention to improve post operative stiffness and gain additional range of motion following TKA in patients who develop stiffness. It can be done even after 12 weeks of surgery with reasonably good gain in range of motion.

MRI Based Comparison of Tibial Bone Coverage by Five Knee Prosthesis: Anthropometric Study in Indians.

This MRI based study evaluates morphological differences of proximal tibia (total cross-sectional area, mediolateral and anteroposterior distance) 8-10 mm distal to the lateral tibial plateau. We evaluated the difference in the coverage of the tibial surface between symmetric and asymmetric tibial trays and difference in coverage between males and females. 150 patients who underwent MRI scans for sports related soft tissue injury without osteoarthritis were studied. The tibial trays of the 5 total knee arthroplasty designs (4 symmetric and 1 asymmetric) were scanned. Mean total tibial coverage of all designs was more than 80%. Asymmetric baseplate had maximum total tibial coverage and maximum rate of optimal fit, with only 2% absolute overhang posterolaterally. Females had better tibial coverage as compared to males.

Management of periprosthetic fracture following total knee arthroplasty- a retrospective study to decide when to fix or when to revise?

PURPOSE: Periprosthetic fractures around total knee arthroplasty are relatively rare complication comprises to 0.3-2.5%. But these injuries are often complex and challenging for the surgeons due to ageing population in conjunction with severe osteoporosis. The management option varies from conservative to internal fixation or revision surgery. Thus this study was conducted to analyze the results of various methods of treatment of periprosthetic fractures following TKA and to form the optimal treatment guidelines for fixation or revision. MATERIAL AND METHODS: 51 cases diagnosed with periprosthetic fracture were enrolled and underwent surgical intervention. Type of primary prosthesis, interval between TKA and periprosthetic fracture, type of fracture, prosthesis stability and mode of fixation of fracture, any revision surgery and complication were noted. RESULTS: The mean age of all patients was 65.89 years. The mean interval between the index surgery and periprosthetic fracture was 6 years (Range 2 months to 10 years) in male and 18.5 months (Range 4 days to 7 years) in female. 44 (86%) fractures were femoral, 4 (8%) fractures were tibial and 3 (6%) fractures were of patella. The mean knee society score (KSS) & oxford knee score (OKS) were found to be good for revision group as compared to the fixation group at final follow up. CONCLUSION: In presence of poor bone stock, far distal fracture configuration, comminution, severe osteoporosis, difficulty in achieving stability with plates & old age-revision TKA is a viable option with stemmed components.

Use of locking compression plates for long bone nonunions without removing existing intramedullary nail: review of literature and our experience.

BACKGROUND: Exchange nailing of ununited fractures with or without bone grafting is the most acceptable procedure for nonunion with previously implanted intramedullary nails. Though excellence of this procedure has been well documented for diaphyseal, noncomminuted fractures of long bones, its acceptability for distal femoral, metaphyseal-diaphyseal junctional fractures, and humeral locations is doubtful. A method of obtaining stability at fracture site is described wherein locking compression plates are applied over the ununited fracture with bone grafting without removal of the underlying nail. METHODS: Eleven patients (six males, five females) with ununited fracture of long bones were enrolled. All these patients had previously undergone locked intramedullary nailing for fractures of long bones (seven femur, two humerus, two tibia). Fracture site was exposed, surfaces rawed, and locking compression plate (AO Synthes) was applied over the intramedullary nail. Eccentric position of the plate allowed one or two bicortical screws adding to the stability of the construct. Interlocking screws if broken were also replaced during the same sitting. Autologous bone grafting was done in all cases. RESULTS: All fractures showed radiologic union at 6.2 months. No complications were encountered. CONCLUSION: Locking compression plating of ununited fracture with preexisting intramedullary nails has predictable good results for specific indications.

Dissociation of Cemented Dual Mobility Socket from the Acetabulum in A Case of Recurrent Total Hip Arthroplasty Instability -A Novel Complication.

INTRODUCTION: Acute complete dissociation of a cemented socket from the acetabular cavity is very rare and has been described only in relation to closed reduction maneuver of a dislocated hip arthroplasty. CASE REPORT: We present a case of recurrent hip dislocation in a 70-year-old female post total hip arthroplasty for which a cemented dual mobility (DM) component was used. The cemented socket dissociated from the acetabular cavity with the polyethylene liner insitul-year post- surgery. It was not related to intraprosthetic dislocation as the acetabular liner-socket interface was not disrupted. A re-revision of the acetabular component was done with an acetabular reinforcement cage, cemented cup, and constraint acetabular liner. No such case of cup dissociation has been reported in the literature till date. CONCLUSION: The use of cemented DM cups without acetabular reinforcement devices has been described recently and is still controversial. Surgeons should be aware of the possibility of such a complication when using metal-backed cemented DM cups.

A muscle sparing posterior approach to the elbow joint for total elbow arthroplasty.

We describe a muscle sparing approach in which the triceps is elevated without injuring the muscle or disturbing its insertion. The entire extensor mechanism is preserved in continuity, thus preventing any extensor weakness. This can be used preferentially in cases of non-union intraarticular distal humerus fractures planned for Total Elbow Arthroplasty.

Comparison of two amoxicillin/clavulanic acid-resistant profiles employing two types of assay disks: A pilot study in 50 isolates from a tertiary care hospital in India.

BACKGROUND: During a period from January to March 2005, there was a sudden 3.85-fold increase in isolates with in vitro resistance to amoxicillin/clavulanic acid at Sant Parmanand Hospital, a private tertiary care hospital in Delhi, India, without an increase in treatment failures. OBJECTIVE: This pilot study was designed to assess whether 2 different brands (one exclusively used during the last quarter of 2004, one exclusively used during the first quarter of 2005) of antibiotic disks used at the hospital were related to the reported change in resistance pattern. METHODS: During April 2005, 50 consecutive hospital isolates, 45 gram negative and 5 gram positive, were tested in parallel, employing 2 brands of amoxicillin/clavulanic acid disks: HiMedia disks (HiMedia Laboratories, Mumbai, India) and BBL(TM) Sensi-Disc(TM) Antimicrobial Susceptibility Test Discs (BD Diagnostic Systems, Sparks, Maryland). RESULTS: Of 50 consecutive hospital isolates tested with the HiMedia disks, 40 were resistant and 10 were susceptible. Of those tested with the BBL disks, 10 were resistant and 40 were susceptible. The susceptibility profiles observed were significantly different (P<0.001). CONCLUSION: In this study, significantly different susceptibility results were found when 2 different brands of antibiotic disks were used to test the amoxicillin/clavulanic susceptibility of 50 consecutive isolates in this private hospital in India.

Osteoid Osteoma of Distal Phalanx of Middle Finger-A Diagnostic Dilemma.

Osteoid Osteoma is benign bone forming tumor which commonly occurs in long bones of lower limb. Presence of these rare tumors in the distal phalanx of the digits of the hand is considered a rare phenomenon. In hand, they usually present as chronic pain, swelling, nail enlargement and increase in size of digit. Diagnosis is challenging with clinical examination and usual imaging modalities and often confused with glomus tumor, enchondroma, infection, trauma and rheumatic disease. Surgical excision of the tumor, if present in hand, is the treatment of choice that aids in coming to the exact diagnosis too. The aim of the paper is to report yet another uncommon case of osteoid osteoma of distal phalanx of middle finger mimicking glomus tumor.

Total knee arthroplasty in women with asymptomatic urinary tract infection.

PURPOSE: To compare early outcome after total knee arthroplasty (TKA) in women with a positive or negative urine culture. METHODS: 128 women underwent bilateral (n=89) or unilateral (n=39) primary TKA. Diabetes mellitus was present in 38%, obesity in 53%, and asymptomatic urinary tract infection (positive urine culture) in 36% of women. Women with a positive or negative urine culture were compared. RESULTS: In the 46 women with a positive urine culture, Escherichia coli (n=29) and Klebsiella (n=17) were grown. Women with a positive or negative urine culture were comparable in terms of the incidence of diabetes (28% vs. 43%, p=0.1), obesity (52% vs. 54%, p=0.87), fever (9% vs. 15%, p=0.32), leucocytosis (28% vs. 17%, p=0.13), and delayed wound healing (0% vs. 1%, p=0.45). CONCLUSION: Women with or without a positive urine culture had comparable early complication rates following TKA.

Private sector hospital response to the 2003 dengue outbreak in the Indian capital metropolis of Delhi.

During 2003, the Indian capital metropolis of Delhi was afflicted with an outbreak of dengue. A private-sector tertiary care hospital responded instantly to the sudden influx of 162 patients during an 8-week interval. That was an unusual challenge because, until 1997, the hospital had exclusively managed patients with ophthalmic disorders. Dengue patients received fiscal concessions and several free services. A multidisciplinary cell was commissioned for case management. Apart from a diagnosis of patients with dengue and their clinical management, suspected or confirmed dengue episodes were instantly reported to health authorities. Anti-mosquito measures in the hospital premises including residential areas for the nursing personnel prevented any local virus transmission. The integrated therapeutic and public health response was associated with a 1.23% case fatality rate. The protocol developed during the dengue outbreak would address every locally reportable disease in the future.

Impact of clinical syndrome-wise categorisation of antimicrobial susceptibility profiles on nosocomial isolates in a tertiary care hospital in Delhi, India.

The objective of this study was to investigate the impact of clinical syndrome-wise categorisation of antimicrobials on the antibiotic susceptibility of nosocomial bacteria at a tertiary care hospital in Delhi, India. The susceptibility of 226 nosocomial bacterial isolates collected during 2008-2011 to meropenem, piperacillin/tazobactam, cefepime, tigecycline, amoxicillin/clavulanic acid (AMC), amikacin, ceftriaxone and ciprofloxacin was monitored and was compared with the antibiotic susceptibility profiles of 72 isolates collected during 2002-2007. During 2008-2011, the isolates included 85% Gram-negative isolates and 15% meticillin-sensitive staphylococci. There was no difference in the susceptibility of the isolates between 2002 and 2007 and 2008-2011, except for a significant increase in Escherichia coli isolates susceptible to AMC (from 73% to 100%), amikacin (70-100%) and cefepime (22-86%), in Klebsiella isolates susceptible to ciprofloxacin (from 25% to 80%) and cefepime (45-75%) and in Pseudomonas isolates susceptible to AMC (from 25% to 86%). In conclusion, during the past decade a clinical syndrome-wise categorisation of antimicrobials in frequent usage as well as culture-based categorisation of infections into nosocomial/community-acquired was useful in establishing the generally insignificant change in the susceptibility of nosocomial isolates and an upsurge in the susceptibility of some isolates to a few antimicrobials. Regular updates on drifts in the antimicrobial susceptibility of local isolates and surveillance of nosocomial infections would be valuable for tackling the emergence of antibiotic-resistant bacteria.

A combined culture-based methodology for surveillance of hospital-acquired infections and timely remedial action in a tertiary care hospital in Delhi, India.

The mortality, morbidity and economic loss accompanying hospital acquired infection (HAI) needs constant surveillance. The usefulness of an integrated culture-based watch on the incidence of HAI was established at a tertiary care, multidisciplinary hospital in Delhi. Isolates from all culture-positive hospitalized cases including antibiotic susceptibility profiles were shared instantly with clinicians and nursing personnel. HAI categorization was based on the interval between hospital admission and isolation of a pathogen. The monthly incidence of HAI was calculated as episodes per 100 admissions, while the nature of HAI isolates including infection sites were computed annually. During 2008 to 2010, the monthly HAI rates ranged from 0 to 0.9 per 100 admissions, with no significant difference in annual incidence (P = 0.45, Kruskal Wallis). There was a subtle but insignificant change in HAI localization in urine, blood, pulmonary tissues or surgical sites of the patients (P = 0.104). While 197 of the 229 isolates were Gram-negative, Klebsiella species, E Coli, Pseudomonas aeroginosa, there were 32 methicillin-sensitive Staphylococcus aureus (P < 0.0001). The combined strategy of constant surveillance of all culture-positive hospitalized cases and dialogues with clinicians, and nursing personnel enabled a monitoring of HAI incidence and ensured freedom from any spikes of HAI episodes or their cross infection, it was possible to monitor the incidence of HAI and to ensure there were no episodes on any spikes or a cross-infection. An identical nonstop approach should result in an earlier detection and management of HAI.

Gender-specific high-flexion knee prosthesis in Indian women: a prospective randomised study.

PURPOSE: To compare outcomes in Indian women who underwent total knee arthroplasty (TKA) using the standard Legacy Posterior Stabilised (LPS) versus the gender-specific LPS high-flexion knee prosthesis. METHODS: 100 women (200 knees) aged 60 to 80 years with an arc of flexion of ≥90º underwent simultaneous sequential TKA for primary osteoarthritis of both knees. They were randomised to receive the standard NexGen LPS prosthesis (n=50) or the gender-specific NexGen LPS High-Flex prosthesis (n=50). Both knees in each patient received the same prosthesis. The resected bone from the posterior femoral condyle was 2 mm greater when the gender-specific prosthesis was used. Patients were followed up at 3, 6, 12, and 24 months. Range of motion, Knee Society score, and Hospital for Special Surgery score were evaluated pre- and post-operatively by a single assessor. RESULTS: The mean follow-up duration was 2.1 (range, 1.6-2.5) years. Respectively for the standard and gender-specific groups, the mean range of motion was 111º and 112º preoperatively and 120º and 123º at the latest follow-up. The gender-specific group gained approximately 3º more in range of motion (p=0.007). The Knee Society score and the Hospital for Special Surgery score between groups were not significantly different pre- and post-operatively. CONCLUSION: The perceived advantage of a gender-specific prosthesis over a standard prosthesis did not translate into better clinical and functional outcome scores.

Hypovitaminosis D3 in menopausal women in a tertiary care hospital in Delhi.

Blood samples from 126 menopausal women, seeking treatment for different ailments at a tertiary care, multidisciplinary hospital in Delhi, India, were examined for their vitamin D(3), quantified by 25-hydroxvitamin D (25-OH-D) level. Using a direct ELISA kit, the 25-OH-D levels were measured and were found to be sufficient in 30 (23.8%) cases, adequate in 10 cases (7.9%) and deficient in 86 cases (68.2%). Severe hypo-vitaminosis in menopausal women in the Indian subcontinent ought to be treated with oral or parenteral supplementation. Point-of-care assay formats are needed for quantification of 25-OH-D levels at healthcare centers.