The Impact of De-Roofing of Lateral Calcaneal wall in Open Reduction and Internal Fixation of Intra-Articular Fractures: Clinico-Radiological Outcomes of a Novel Technique and Review of Literature.

Background: Most displaced intra-articular calcaneus fractures need to be treated surgically but postoperative soft tissue complications limit to achieve of optimal functional outcomes. Certain mini-invasive techniques lead to better soft tissue healing but anatomical reduction gets compromised. Objectives: We aim to evaluate the results of lateral wall de-roofing of the calcaneum to achieve good anatomical reduction as well as to minimise soft tissue complications in the internal fixation of calcaneal fractures. Materials and Methods: Thirty-two patients (40 ft) with displaced intra-articular calcaneus fractures (10 were of Sanders type II, 16 were of type III, and 14 were of type IV) were treated between January 2018 and September 2021. All patients were managed surgically with open reduction and internal fixation using lateral extensile approach combined with de-roofing of the lateral wall. All patients were followed up for ≥1 year using functional parameters American Orthopaedic Foot and Ankle Score (AOFAS), visual analogue scale (VAS) and radiological parameters (Bohler angle, Gissane angle, height of the calcaneus, width of the calcaneus and pitch of calcaneus). Results: Out of 32 patients, one patient lost to follow-up. At 1 year follow-up, mean AOFAS hindfoot score was 86.2 ± 5 (Sanders type II: 91.2, Sanders type III: 87.6, and Sanders type III: 81.4), mean VAS score was 91.3 ± 2.1, mean Bohler angle (°) was 27.2 ± 4.7, mean Gissane angle (°) was 136.4 ± 5.2, mean calcaneus height was 46.2 ± 2.1 mm and mean calcaneus width was 45.1 ± 3.2 mm. Patients with decreased Bohler angle between postoperative images and follow-up had lower AOFAS hindfoot scores. Complications included persistent swelling (64.10%), stiffness (33.33%), superficial infections (5.12%), and wound dehiscence (10.25%). Conclusion: Lateral wall de-roofing is a useful technique which allows the lateral wall to get flattened reducing soft tissue complications and providing bone graft as well. This approach also adequately exposes fracture fragments, subtalar and calcaneocuboid joints for good anatomical reduction. Hence, it can act as a useful adjunct in the internal fixation of intra-articular calcaneus fractures. Level of Evidence: III.

Medial tibial bone resorption following total knee arthroplasty comparing a traditional with a kinematic design.

BACKGROUND: New total knee prostheses are being designed to improve clinical outcome, survivorship and patient satisfaction following total knee arthroplasty (TKA). A new knee system was developed with improvements in patellofemoral joint, trochlear geometry, polyethylene formulation and tibial baseplate. Aim of this study was to compare the newer kinematic knee system with its existing predecessor knee system in terms of clinical outcome, revision rates, radiographic outcomes specifically medial tibial bone resorption. METHODS: The prospective matched-pair study included 88 TKA surgeries using newer kinematic design knee prostheses, performed between January 2015 and December 2016, out of which 82 patients were available for final follow-up. The control cohort of 82 traditional TKA prosthesis was matched in terms of age, gender and body mass index. All surgeries were performed by the single surgeon using medial parapatellar arthrotomy and posterior stabilized implants were used. Clinical outcomes were assessed using knee society score, range of motion (ROM), anterior knee pain and crepitation. Radiological examinations included recording of radiolucent lines and medial tibial bone resorption. RESULTS: At the 5-year follow-up, no significant differences were noted in terms of mean knee society score (93.3 ± 6.6 vs 94.2 ± 8.1), knee function score (88.5 ± 10.5 vs 89.1 ± 11.2) and ROM. The incidences of anterior knee pain and crepitation were lower in the newer group (8.5% vs 21.9% and 14.6% vs 32.9%, respectively) compared to the traditional prosthesis group. No cases of aseptic loosening were observed in either cohort. No significant difference was seen in terms of radiolucent lines (29.3% vs 26.8%) and medial tibial resorption (2.43% in each group) incidences. CONCLUSIONS: At the 5 years follow-up no significant differences were noted between the two groups in terms of clinical and radiological outcomes, except the former proved to be better for anterior knee pain and crepitation. LEVEL OF EVIDENCE: II.

The application of low-dose dexamethasone in total knee arthroplasty: finding out the best route and dosage schedule.

BACKGROUND: The use of dexamethasone as additive to multimodal analgesic regimen in total knee arthroplasty has been well established, but the most suitable route, effectiveness, safety and dose schedule of low-dose dexamethasone is not known. METHODS: We conducted a prospective, randomized, double-blinded trial to investigate and compare the analgesic and antiemetic effects and safety of low-dose (8 mg) dexamethasone introduced as periarticular injection or intravenous (as a single dose or in two divided doses of 4 mg separated by 24 h) in unilateral total knee arthroplasty patients. RESULTS: The single dose intravenous administration as well as the periarticular administration of dexamethasone had similar mean visual analogue scores which were significantly lower than divided dose group at 24 and 48 h postoperatively. The rate of postoperative nausea and vomiting was lowest among single intravenous dose group and highest among interval dose group at 24 h, while no difference was noted at 48 h. No significant differences were noted in terms of knee flexion angle at 48 h and modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at 6 weeks. CONCLUSION: Single low-dose intravenous dexamethasone is the most appropriate dose which can safely be given to TKA patients and is only moderately associated with rise in blood sugar not causing any significant complication. Alternatively, periarticular infiltration of low-dose dexamethasone can produce equivalent analgesic effect as SDIV in first 24 h without causing significant blood sugar rise and wound complications, but its antiemetic effect remains subtle. Therefore, it is recommended to further study the combination of intraoperative periarticular and postoperative intravenous dexamethasone for their possible additive effect.

A three-dimensional gadolinium organic framework based on a pyridinedicarboxylic acid organic linker with a paddle-wheel-type network structure.

A new gadolinium(III)-pyridine-2,5-dicarboxylic acid (GdIII-2,5-H2pdc)-based three-dimensional coordination polymer, namely, poly[dimethylazanium [bis(µ-pyridine-2,5-dicarboxylato)gadolinium(III)]], {[(CH3)2NH2][Gd(C7H3NO4)2]}n, CP-1, has been synthesized via a typical solvothermal method. The as-synthesized material was characterized in the solid state using single-crystal X-ray diffraction, powder X-ray diffraction, thermogravimetric analysis and FT-IR spectroscopy. During the synthesis of CP-1, the in situ dimethylformamide (DMF) promotes the formation of a dimeric unit and these act as secondary building blocks in the assembly of a three-dimensional anionic {[Gd(pdc)2]-}∞ framework. The framework has channels along the c axis which are filled by dimethylazanium cations. Interestingly, the framework shows a helical-type assembly running down the a axis. A Hirshfeld surface analysis of CP-1 suggests that extra stability is provided by hydrogen-bonding interactions. The magnetic properties of CP-1 showed weak antiferromagnetic couplings between adjacent Gd3+ ions.

"Floating Hip" and "Floating Knee" Associated with Hip Dislocation, Sciatic Nerve Palsy, and Patella Fracture: A Case Report.

CASE: We report a very rare case of simultaneous ipsilateral floating hip and floating knee (SIFHFK) injury with the neck of the femur and patella fracture and hip dislocation associated with sciatic nerve injury in a 45-year-old man after a road traffic accident. We adopted a staged approach for surgical fixation of the fractures after stabilization. At the latest 2 years follow-up, the patient was asymptomatic with satisfactory clinical outcome. CONCLUSION: SIFHFK injuries present a challenging and emergent clinical scenario and require extensive clinical experience, careful planning, and multidisciplinary teamwork because of the paucity of specific treatment protocols for the treatment of this complex injury.

Analysis of clinical and radiological outcomes of long tibial stemmed total knee arthroplasty in knee osteoarthritis complicated by tibial stress fracture.

OBJECTIVE: Knee arthritis associated with tibial stress fractures represents an uncommon and difficult clinical scenario to treat. The use of long, fluted tibial extension rods has been vital in the management of such cases owing to immediate fracture stability and single-stage surgery without the need to open the fracture site. This study investigates clinical and radiological outcomes following total knee arthroplasty using a tibial extension stem in cases of knee osteoarthritis with tibial stress fracture. METHODS: From February 2015 to December 2020, 17 patients who had total knee arthroplasty implanted with a long stemmed tibial component were included in the study. Patient data were analyzed for knee range of motion, deformities, Knee Society score, knee function score, and time to fracture union in the pre- and postoperative periods. RESULTS: The mean follow-up duration was 22.7 ± 11.68 months (range 12-60 months), and mean time to fracture healing was 10.23 ± 2.81 weeks (range 8-20 weeks). The preoperative mean fixed flexion deformity improved from 8.53 ± 3.43° to a mean of 0.29°, and knee flexion improved from 79.4 ± 13.90° to 125.29 ± 8.74° on postoperative assessment. The Knee Society score improved from a mean preoperative score of 18.94 ± 5.55 (range 8-28) to 89.41 ± 7.5 (range 74-102, p value < 0.001). Similarly, the knee function score improved significantly from a mean preoperative score of 15.5 ± 4.48 (range 8-26) to a mean of 85 ± 6.09 (range 72-94, p value < 0.001). CONCLUSION: Total knee arthroplasty using long tibial extenders has been an effective and safe surgical option for patients with advanced osteoarthritis with tibial stress fractures.

Calcaneal osteomyelitis caused by Acremonium sp in an immunocompetent adult - A case report.

Fungal osteomyelitis of calcaneus is rare in immunocompetent adults. A case of fungal osteomyelitis of calcaneus in a 19 year old immunocompetent female without any history of trauma caused by Acremonium sp is presented. The patient was treated with surgical debridement, autogenous iliac crest bone grafting and antifungal chemotherapy for 6 months. At latest follow up after 2 years, patient is asymptomatic and the osteolytic lesion is healed with no signs of recurrence. This case report highlights a rare presentation of chronic painful calcaneal osteomyelitis with an osteolytic lesion.

Clinical and Surgical Insights on Bilateral Total Knee Arthroplasty in Ochronotic Arthropathy: A Case-based Review.

Introduction: Ochronotic arthropathy (OcA) is a consequence of alkaptonuria, a rare systemic-inherited metabolic disorder leading to accumulation of homogentisic acid in articular cartilage and subsequent early degeneration of the joints. Only few cases of OcA managed with bilateral total knee arthroplasty (TKA) has been described in the literature so far. We aim to discuss surgical pearls, pitfalls, and clinical outcome of OcA of knees managed with simultaneous bilateral TKA. Case Presentation: The patient was a 52-year-old female presented to outpatient facility with severe bilateral knee pain and difficult ambulation. After clinical and radiological diagnosis of osteoarthritis, she was posted for bilateral TKA. During arthrotomy, blackening of articular cartilage, quadriceps and patellar tendon, and synovium was noted. Subchondral bone was free of pigmentation though, seemed osteopenic while taking bone cuts. Right knee was implanted with cruciate retaining components with ultracongruent insert; while on the left side, posterior stabilized components were used. Diagnosis of ochronosis was made retrospectively with characteristic subtle pigmentation of nails, palms, pinnae, and urine homogentisic levels. Two years follow-up of the patient remained satisfactory without any major complications. Conclusion: OcA may present with intra-operative surprise to the surgeon if not anticipated preoperatively. Simultaneous bilateral TKA is safe and effective treatment for end-stage arthritis. However, it is difficult to diagnose it preoperatively; a high clinical suspicion leads to meticulous assessment and counseling regarding potential anesthetic concerns, choice of implant, and possible intra-operative and post-operative complications reported sporadically though.

Stress Fracture of Isolated Middle Cuneiform Bone in a Trainee Physician: A Case Report and Review.

Stress fractures are chronic fatigue failure of bone from repetitive subthreshold loads. Insufficiency fractures occur in bones that are already osteopenic and fail to withstand normal loads over time. Stress fractures of cuneiform bones are extremely rare and usually reported to happen in athletes or recruits. We describe a case of middle cuneiform insufficiency fracture that occurred in a young trainee physician with severe hypovitaminosis D, who joined his training a few weeks before it happened. Magnetic resonance imaging remains the modality of choice of diagnosis of foot stress injuries because it detects even stress reactions with reasonable sensitivity. Cuneiform stress fractures, like other low-risk stress fractures, heal with immobilization only and do not require surgical intervention.

Disassembly of Components of a Monoblock Bipolar Hip Prosthesis Following Dislocation: A Case Report and Review on "Bottle Opener Effect".

INTRODUCTION: Bipolar hemiarthroplasty has been reliable and successful treatment for geriatric patients following neck of femur fractures. Dissociation/disassembly of bipolar prosthesis is a rare complication in which separation of outer head from inner head leads to failure of prosthesis and needs revision surgery. The disassembly though commonly seen after years of primary surgery as a result of polyethylene wear leading to fixed varus position of outer head but it can happen in an acute setting anytime in immediate or late post-operative period following posterior dislocation with closed reduction attempt. We describe a rare case of disassembly of monoblock (non-modular) bipolar prosthesis following attempt of closed reduction for posterior dislocation of the prosthesis. CASE REPORT: The patient was a 70-year-old male with 3 weeks prior bipolar hemiarthroplasty of hip joint, presented with posterior dislocation. While manipulation during closed reduction maneuvers, the outer head got locked behind acetabulum and component dissociation happened through bottle opener phenomena. The patient managed with revision surgery in the form of bipolar extraction and revision with total hip joint prosthesis. CONCLUSION: Disassembly of bipolar prosthesis is a rare and unforeseen complication which obviates for revision surgery. A modular bipolar prosthesis can be reassembled or can be managed with shell, liner, and head exchange with retention of femoral stem but it is impossible to reassemble a non-modular bipolar due to its characteristic locking mechanism. It is vital to look for proper orientation and stability of components, integrity of abductor mechanism and short external rotators, and restoration of horizontal and vertical offsets during revision.

Synthesis and characterization of carbonate-encapsulated ytterbium- and yttrium-containing polyoxotungstates.

A sandwiched-type carbonate-encapsulated yttrium-containing arsenotungstate(III) has been synthesized under mild reaction conditions. The polyanion [NaCH3COO{Y2(H2O)3(B-α-AsW9O33)2(W2O5)(CO3)}]12- (1) was isolated as a solid crystalline material by the reaction of a YIII salt with the sodium salt of trilacunary [AsW9O33]9- in sodium acetate solution. The sodium salt of the polyanion, i.e. Na12[Na(CH3COO){Y2(AsW9O33)2(W2O5)(CO3)(H3O)3}]·22H2O (1a), was characterized by various analytical techniques, such as FT-IR, single-crystal X-ray diffraction (SC-XRD), TGA (thermogravimetric analysis), 13C NMR and ESI-MS (electrospray ionization mass spectrometry). SC-XRD studies revealed that the polyanion crystallizes in the triclinic space group P-1. The structure showed that the polyanion is a carbonate-encapsulated sandwich-type species, consisting of two trilacunary B-α-[AsW9O33]9-, with a lone-pair-containing AsIII heteroatom, together with two extra tungsten centres and two yttrium cations at the sandwich position, where CH3COO- and Na+ ions act as linkers between the two polyanion units. In addition, we have also synthesized two carbonate-encapsulated germanotungstates(IV), without lone-pair-containing heteroatoms, with the formula [Ln3(A-ß-GeW9O34)2(CO3)(H2O)3]13- [Ln = YIII (2) and YbIII (3)], i.e. Y2K3Na4[Y3(A-ß-GeW9O34)2(CO3)(H2O)3]·19H2O (2a) and YbK8Na2[Yb(A-ß-GeW9O34)2(CO3)(H2O)3]·16H2O (3a), and characterized them by FT-IR, SC-XRD, TGA and ESI-MS. Here, the lanthanide ions act as linkers, extending the structures into higher dimensions. Sodium and potassium ions also play a key role as linkers, further extending the structure. The packing shows the presence of certain hydrophilic pores within the structure.

Biological Reconstruction of Knee Joint by Pedicled Patellar Transplant in a Recurrent Giant-cell Tumor of Lateral Femoral Condyle: A Case Report.

INTRODUCTION: Giant-cell tumors (GCTs) are benign tumors of musculoskeletal system, commonly occur around knee. High-grade GCTs have a high tendency to recur after intralesional curettage. Reconstruction of joint after excision of such aggressive juxta-articular GCT has been challenging task. We describe a case of recurrence in GCT of lateral femoral condyle managed with tumor excision and pedicled patellar transplant to reconstruct the joint. CASE REPORT: A 25-year-old male patient reported to us after 22 months after he had undergone curettage and bone grafting for GCT of lateral femoral condyle of his right knee with recurrence of primary tumor. After tumor resection, we restored the lost articular surface with musculovascular pedicled patella and managed dead space with corticocancellous bone graft and fibular strut. 2-year follow-up exhibited good functional outcome without any sign of recurrence. CONCLUSION: Biological reconstruction with patellar transplant can be a good option for young patients in whom endoprosthesis placement poses significant concerns about longevity, cost, and revision surgeries.

Lanthanoid containing phosphotungstates: the syntheses, crystal structure, electrochemistry, photoluminescence and magnetic properties.

A series of ten mononuclear lanthanoid containing phosphotungstate clusters were synthesized by the reaction of the dilacunary ligand [P2W19O69(H2O)](14-) with Ln(NO3)3·xH2O in a potassium acetate buffer (pH 4.8), leading to the formation of Peacock and Weakley type dimers [Ln(PW11O39)2](11-) (Ln = Pr(3+) (1), Nd(3+) (2), Eu(3+) (3), Gd(3+) (4), Tb(3+) (5), Dy(3+) (6), Ho(3+) (7), Er(3+) (8), Tm(3+) (9), and Yb(3+) (10)). All isostructural molecular clusters were structurally characterized using various analytical techniques like FT-IR, (31)P NMR spectroscopy, photoluminescence and solid state UV/vis, electrochemistry, magnetism and single crystal X-ray diffraction. The compounds crystallize as mixed potassium/caesium or potassium salts K11[Ln(PW11O39)2]·xH2O (Ln = Pr(3+) (1a), Nd(3+) (2a), Eu(3+) (3a), Gd(3+) (4a), Tb(3+) (5a), Dy(3+) (6a), Ho(3+) (7a), Er(3+) (8a), and Tm(3+) (9a), in the monoclinic crystal system, space group P21/c (14) with the exception of the Gd(4a) and Ho(7a) complexes which crystallize in the triclinic system, space group P1[combining macron]. The prominent effect of the paramagnetic lanthanoid ion along the group on the monolacunary Keggin unit (α-PW11O39) was illustrated by FT-IR and (31)P NMR spectroscopy. This is attributed to its small size and high charge density (lanthanoid contraction). The photoluminescence of the molecular clusters Eu(3a), Dy(6a) and Ho(7a) was studied at room temperature at different excitation wavelengths and shows interesting photochromic properties. The voltammetric patterns associated with the W-centers in the cluster series have enough distinct features to allow us to establish the relative basicity of the reduced polyoxometalates: {PW11} > Tm(9a) > Eu(4a) ≈ Tb(5a) ≈ Ho(7a) > Gd(4a) ≈ Dy(6a) ≈ Er(8a). Among the lanthanoid cations, just the Eu(3+) centre turned out to be electroactive, as expected. The magnetic measurement of Gd(4a) shows the paramagnetic behaviour of the material.