A computed tomographic evaluation of femoral and tibial rotational reference axes in total knee arthroplasty.

INTRODUCTION:  The surgical trans epicondylar axis (sTEA) is considered the gold standard for optimum rotation of the femoral component; however, no consensus exists on tibial component positioning. The objectives of this study were to determine the relationship of sTEA to various femoral and tibial reference axes in varus osteoarthritis (OA) knees and (ii) to study the intra-observer and inter-observer variability of the axis relationships. MATERIALS AND METHODS:  The study was done on preoperative computerised tomogram (CT) scans of 110 varus knees to assess the rotational relationships respectively of femoral side sTEA with whitesides line (WSL), posterior condylar axis (PCA), clinical trans epicondylar axis (cTEA) and on the tibial side sTEA with posterior tibial margin (PTM), anterior condylar axis (ACA), Akagi's line and line from the geometric centre of the tibial plateau to 1/3rd tibial tubercle (line GC 1/3rd TT). RESULTS:  On the femoral side the mean angles of sTEA with WSL, PCA, cTEA were 95.64° ± 2.85°, 1.77° ± 1.88°, 4.19° ± 0.99° respectively. On the tibial side, the mean angles of sTEA with, PTM, ACA, Akagi's line, and line GC 1/3rd TT were 1.10° ± 4.69°, 11.98° ± 4.51°, 2.43° ± 4.35°, 16.04° ± 5.93° respectively. CONCLUSION:  Contrary to the generalization, TEA has variable relationships. The surgical trans epicondylar axis was not at the assumed 3° of external rotation to PCA in 85% of knees, nor perpendicular to WSL in >95% of knees. Of the four tibial axes, Akagi's line was the least variable with sTEA. Furthermore, surgeons should also be aware of the multiple reference axes and the range of deviation from sTEA to optimize the rotational alignment of components.

Trends in Practice Among Shoulder Specialists in the Management of Frozen Shoulder: A Consensus Survey.

Background: The management of frozen shoulder (FS) differs depending on experience level and variation between scientific guidelines and actual practice. Purpose: To determine the current trends and practices in the management of FS among shoulder specialists and compare them with senior shoulder specialists. Study Design: Consensus statement. Methods: A team of 15 senior shoulder specialists (faculty group) prepared a questionnaire comprising 26 questions regarding the definition, terminology, clinical signs, investigations, management, and prognosis of FS. The questionnaire was mailed to all the registered shoulder specialists of Shoulder and Elbow Society, India (SESI) (specialist group; n = 230), as well as to the faculty group (n = 15). The responses of the 2 groups were compared, and levels of consensus were determined: strong (>75%), broad (60%-74.9%), inconclusive (40%-59.9%), or disagreement (<40%). Result: Overall, 142 of the 230 participants in the specialist group and all 15 participants in the faculty group responded to the survey. Both groups strongly agreed that plain radiographs are required to rule out a secondary cause of FS, routine magnetic resonance imaging is not indicated to confirm FS, nonsteroidal anti-inflammatory drugs should be administered at bedtime, steroid injection (triamcinolone or methylprednisolone) is the next best option if analgesics fail to provide pain relief, passive physical therapy should be avoided in the freezing phase, <10% of patients would require any surgical intervention, and patients with diabetes and thyroid dysfunction tend to fare poorly. There was broad agreement that routine thyroid dysfunction screening is unnecessary for women, a single 40-mg steroid injection via intra-articular route is preferred, and arthroscopic capsular release (ACR) results in a better outcome than manipulation under anesthesia (MUA). Agreement was inconclusive regarding the use of combined random blood sugar (RBS) and glycosylated hemoglobin versus lone RBS to screen for diabetes in patients with FS, preference of ACR versus MUA to treat resistant FS, and the timing of surgical intervention. There was disagreement over the most appropriate term for FS, the preferred physical therapy modality for pain relief, the most important movement restriction for early diagnosis of FS, and complications seen after MUA. Conclusion: This survey summarized the trend in prevalent practices regarding FS among the shoulder specialists and senior shoulder surgeons of SESI.

Trends in Primary Anatomical Single-Bundle Anterior Cruciate Ligament Reconstruction Practice in Adult Patients Prevalent Among Arthroscopy Surgeons of Six Southern States of India.

Background: Although guidelines from multiple scientific studies decide the general trend in ACLR practice, there is often a variation between scientific guidelines and actual practice. Methods: A 17-member committee comprised of sports surgeons with experience of a minimum of 10 years of arthroscopy surgery finalized a survey questionnaire consisting of concepts in ACL tear management and perioperative trends, intraoperative and post-operative practices regarding single-bundle anatomic ACLR. The survey questionnaire was mailed to 584 registered sports surgeons in six states of south India. A single, non-modifiable response was collected from each member and analyzed. Results: 324 responses were received out of 584 members. A strong consensus was present regarding Hamstring tendons preference for ACLR, graft diameter ≥ 7.5 mm, viewing femoral footprint through the anterolateral portal, drilling femoral tunnel from anteromedial portal guided by ridges and remnants of femoral footprint using a freehand technique, suspensory devices to fix the graft in femur and interference screw in the tibia and post-operative bracing. A broad consensus was achieved in using a brace to minimize symptoms of instability of an ACL tear and antibiotic soaking of graft. There was no consensus regarding the timing of ACLR, preferred graft in athletes, pre-tensioning, extra-articular procedure, and return to sports. There was disagreement over hybrid tibial fixation and suture tapes to augment graft. Conclusion: Diverse practices continue to prevail in the management of ACL injuries. However, some of the consensuses reached in this survey match global practices. Contrasting or inconclusive practices should be explored for potential future research.

Short-Term Outcomes of Robotic Lateral Unicompartmental Knee Arthroplasty: An Indian Perspective.

Background: Lateral UKA is a technically more challenging procedure than medial UKA accounting for < 1% of all knee arthroplasties. Robotic UKA for lateral compartment arthritis is rare and has not been reported in India. Materials and Methods: This is a prospective single-centre clinical study of six patients (five females and one male) who underwent robotic-arm-assisted lateral UKA (RALUKA) between May 2018 and January 2020 with patient-specific 3D-CT preoperative plan. Overall satisfaction on a five-level Likert scale, clinical outcome based on the KOOS and MFJS and radiological outcomes based on the HKA axis, femorotibial angle (FTA), tibial posterior slope (PS) obtained were compared preoperatively and postoperatively. Results: At a mean follow-up period of 23.84 months, among six patients 33.3% very satisfied, 50% satisfied and 16.7% felt neutral. The mean KOOS changed from 63.03 ± 3.52 to 93.95 ± 3.25 and the mean MFJS was 75.41 ± 10.29 postoperatively. The mean HKA axis changed from 175.81° ± 2.88 valgus to 179.99° ± 2.14 neutral alignment. The mean correction attained was from 4.19° ± 2.88 valgus deformity to 0.01° ± 2.14. The mean FTA and the mean PS changed from 7.34° ± 4.14 of valgus to 1.92° ± 1.85 of valgus and 83.44° ± 1.77 to 85.38° ± 2.10, respectively. Conclusions: The mean preoperative and postoperative KOOS showed a statistical significance with a p value of < 0.001 (< 0.05), showing significant improvement with RALUKA. RALUKA is a promising surgical option for lateral compartment OA of the knee.

Image-based robot assisted bicompartmental knee arthroplasty versus total knee arthroplasty.

OBJECTIVE: To evaluate the short-term clinical outcomes of image-based robot-assisted bicruciate retaining bicompartmental knee arthroplasty and compare it to robot-assisted total knee arthroplasty in the Indian population. METHODS: Between December 2018 and November 2019, five patients (six knees) underwent robot-assisted bicompartmental knee arthroplasty (BCKA). These patients were demographically matched with five patients (six knees) who underwent robot-assisted total knee arthroplasty (TKA) during the same period. Clinical outcomes of these twelve knees were assessed in the form of knee society score (KSS) score, Oxford knee score (OKS), and forgotten joint score (FJS) after a minimum follow-up period of 25 months. The data between the two cohorts were compared and analyzed. RESULTS: Scores obtained from both cohorts were subjected to statistical analysis. SPSS software was utilized and the Mann Whitney U-test was utilized to compare the two groups. There was no statistically significant difference found between the two groups in terms of functional outcome. CONCLUSION: Image-based robot-assisted BCKA is a bone stock preserving and more physiological procedure which can be a promising alternative to patients presenting with isolated arthritis of only two compartments of the knee. Although long-term, larger trials are warranted to establish it as an alternative, our pilot study shows an equally favorable outcome as TKA, making it an exciting new avenue in the field of arthroplasty.

Accuracy in the Execution of Pre-operative Plan for Limb Alignment and Implant Positioning in Robotic-arm Assisted Total Knee Arthroplasty and Manual Total Knee Arthroplasty: A Prospective Observational Study.

AIM: The objective of the study is to compare the accuracy of implant positioning and limb alignment achieved in robotic-arm assisted total knee arthroplasty(RATKA) and manual total knee arthroplasty(MTKA) to their respective preoperative plan. PATIENTS AND METHODS: This was a prospective observational study conducted in a tertiary care centre between August 2018 and January 2020. 143 consecutive RATKA(105 patients) and 151 consecutive MTKA(111 patients) performed by two experienced arthroplasty surgeons were included. Two independent observers evaluated the accuracy of implant positioning by measuring the radiological parameters according to the Knee-Society-Roentgenographic-Evaluation-System and limb alignment from postoperative weight-bearing scanogram. Outcomes were defined, based on the degree of deviation of measurements from the planned position and alignment, as excellent(0-1.99°), acceptable(2.00-2.99°) and outlier(≥ 3.00°). RESULTS: There were no systematic differences in the demographic and baseline characteristics between RATKA and MTKA. Statistically significant outcomes were observed favouring robotic group for postoperative mechanical axis (p < .001), coronal inclination of the femoral component (p < 0.001), coronal inclination of tibial component (p < 0.001), and sagittal inclination of tibial component (p < 0.001). There was no significant difference in the sagittal inclination of the femoral component (p = 0.566). The percentage of knees in the 'excellent' group were higher in RATKA compared to MTKA. There was absolutely no outlier in terms of limb alignment in the RATKA group versus 23.8% (p < 0.001) in the MTKA group. All the measurements showed high interobserver and intraobserver reliability. CONCLUSION: Robotic-arm assisted TKA executed the preoperative plan more accurately with respect to limb alignment and implant positioning compared to manual TKA, even when the surgeons were more experienced in the latter. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-020-00324-y.

A long-term cross-sectional study with modified forgotten joint score to assess the perception of artificial joint after total knee arthroplasty.

BACKGROUND AND PURPOSE: The ultimate goal for an arthroplasty surgeon is to provide the patient a joint that feels more like a natural joint. The Modified Forgotten Joint Score (MFJS) is a newly introduced functional scoring system that has a superior ability to assess this property among arthroplasty patients. The objective of this study is to evaluate the long-term temporal association of the MFJS and total knee arthroplasty (TKA). METHODS: We assessed 360 patients post TKA with MFJS questionnaire. The patient groups were distributed at follow-up intervals of 3 weeks (n = 55), 6 months (n = 45), 1 year (n = 57), 2 years (n = 40), 3 years (n = 49), 5 years (n = 49), 7 years (n = 39), and 10 years (n = 26). Higher score suggests a forgotten artificial joint. RESULTS: Post-operative mean MFJS scores were 64.4 ± 7.6 at 3 weeks, 87.7 ± 5.6 at 6 months, 89.2 ± 3.1 at 1 year, 89.9 ± 2.6 at 2 years, 89.4 ± 3.2 at 3 years, 89.1 ± 4 at 5 years, 84.5 ± 8.8 at 7 years, and 82.7 ± 11.9 at 10 years. The score at 3 weeks was significantly lesser than the average scores at other follow-up intervals. The score at 6 months was significantly higher compared to the score at 10 years. The average score at 1 year, 2 years, 3 years, and 5 years were significantly higher compared to the average score at 7 years and 10 years. CONCLUSION: The trend of the MFJS score was found to drastically improve from 3 weeks to 6 months and peak in 2 years after which the score tends to attain a plateau up to 5 years following which there is a decline in the score at 7- and 10-years post-surgery. Age did not have an influence on the variation in functional score in any of the follow-up groups. MFJS has a strong positive correlation with the well-recognised KOOS scoring system. LEVEL OF EVIDENCE: IV.

Fatigue fracture of the femoral component in total knee replacement.

BACKGROUND: Fracture of femoral component in total knee arthroplasty (TKA) has become a rare complication with improvements in metal alloy manufacturing technology. METHODOLOGY: We report two cases of fracture of femoral components 9 and 10 years after primary TKA. The Buechel-Pappas (BP) knee system used in our two cases were designed by the same team who designed the LCS TKA implants. The femoral component is made of cobalt chromium alloy. The break in the femoral component noted in both the cases were at a similar site, at the distal medial flange just posterior to the peg of the femoral component. RESULT: Both these cases underwent revision surgery using stemmed implants with good results. Implants retrieved were analysed with Scanning Electron Microscopy (SEM) and Energy Dispersive X-ray Spectroscopy (EDS) to study the fracture pattern and material properties respectively. Fractography analysis of both our cases showed that the crack initiated laterally from the thin edge (1mm) around the sharp angulated corner of the medial femoral condyle and spread medially towards the thicker segment. CONCLUSION: We feel two fractures of femoral component out of 9000 TKA in ten years is significant. We recommend a re-evaluation of the femoral component of the BP knee system to ensure that the edges, specifically the sharp corners, have adequate thickness to avoid a fatigue fracture.

Accuracy of tibial component positioning in the robotic arm assisted versus conventional unicompartmental knee arthroplasty.

BACKGROUND: Our study aims to determine the planned accuracy of the tibial component placement in robotic arm assisted unicompartmental knee arthroplasty (UKA) versus the conventional jig based UKA of the initial cases done in India for the first time with this particular robotic system.Materials & Methods: Study group 1 consisted of patients who underwent robotic arm (MAKO, Stryker, USA) assisted UKA. Group 2 consists of patients who underwent a standard conventional jig based (Oxford knee, Biomet, UK). Post-operative radiographs were taken to determine the Tibial Implant position and orientation which were compared to their preoperative plan respectively by two independent observers. The mean error value was obtained for both study groups respectively and compared to determine the accuracy of the post-operative tibial implant placement. RESULTS: In the Robotic arm assisted UKA, the deviation of post-operative varus angle from preoperative planned angle was about 0.43° and post-operative Tibial slope alignment differed from preoperative plan was 0.41°. In the Conventional UKA group post-operative varus angle differed from preoperative planned angle by about 2.12° and post-operative Tibial slope alignment deviation from preoperative plan was 2.47°. CONCLUSIONS: Robotic arm assisted system was more accurate compared to the conventional jig-based technique in achieving the planned orientation and alignment of the tibial implant in the initial learning phase of this particular Robotic System used for the first time in India. MESH TERMS: partial knee replacement, robotic assisted surgery.

Long-Term Comparison Study of Patella Resurfacing Versus Non-resurfacing in Total Knee Arthroplasty with Minimum 10-Year Follow-Up.

BACKGROUND: Management of the patella during total knee arthroplasty is a matter of constant debate. Numerous studies have assessed and compared the mechanical and clinical results of total knee arthroplasty with native as well as resurfaced patellae. However, the consensus has not been reached yet on this subject. This study aims to compare the outcome between patella resurfaced (PR) and non-resurfaced patellae (NPR) after a follow-up of minimum 10 years following total knee arthroplasty. MATERIALS AND METHODS: This is a retrospective study including 63 subjects (103 knees) who had undergone total knee arthroplasty with a follow-up of 10-14 years. In this study, we evaluated the knees implanted with either press fit condylar (PFC) sigma (Depuy, Johnson & Johnson) or Nexgen (CR flex/LPS flex) (Zimmer, Warsaw, Indiana, USA) implants. Whether to perform patella resurfacing or not and choice of implants as well as implant design (posterior stabilized/cruciate retaining) was surgeons' preference. At final follow-up, clinical and functional outcome was assessed using Knee Society Scores (KSS), and comparison of difference between pre-op scores and scores at final follow-up among resurfaced versus non-resurfaced patellae groups was carried out. Patello-femoral function was assessed at final follow-up using Feller's score and the results were compared between resurfaced and non-resurfaced patellae. RESULTS: The mean follow-up was 140 months (range 124-168 months). There were 62 knees with their patella resurfaced and 41 knees with non-resurfaced patellae There was no significant difference in the mean pre-op Knee Society Scores between PR (46.29 ± 5.17) and NPR (47.34 ± 5.95), p value 0.34. Similarly there was no significant difference in their pre-op functional score as well PR (38.53 ± 5.14) and NPR (39.22 ± 6.79), p value 0.56. Both groups had significantly improved post-operative Knee Society Scores PR (85.95 ± 5.23) and NPR (84.65 ± 5.30). However, there is no difference between these groups, p value 0.22. Functional scores also maintained significant improvement at final follow-up. Between the two groups, the resurfaced group showed a significantly higher functional score at final follow-up: PR (70.90 ± 7.73) and NPR (66.44 ± 7.12), p value 0.02. Feller's score at final follow-up for PR group was (23.36) and NPR group was (21.98), p value 0.001, which showed clear superiority of PR over NPR. CONCLUSION: After a minimum follow-up of 10 years, there were no differences in clinical results; however, the knee function score and patello-femoral function scoring was found to be significantly higher with patella resurfacing and it was persistent across all the subgroups we had included in the study-posterior stabilized/cruciate retaining or between implants made by two different manufacturers.

Ceramic Bone Graft Substitutes do not reduce donor-site morbidity in ACL reconstruction surgeries: a pilot study.

INTRODUCTION: Anterior knee pain is a major problem following Bone-patellar-tendon-bone graft (BPTB) use in anterior cruciate ligament (ACL) reconstruction. We hypothesized that filling the donor defect sites with bone-graft substitute would reduce the anterior knee symptoms in ACL reconstruction surgeries. MATERIAL AND METHODS: Patients operated for ACL-deficient knee between March 2012 and August 2013 using BPTB graft were divided into two treatment groups. The patellar and tibial donor-site bony defects were filled-up with Hydroxyapatite-Bioglass (HAP:BG) blocks in the study group (n = 15) and no filler was used in the control group (n = 16). At 2 years, the clinical improvement was assessed using International Knee Documentation Committee (IKDC) score and donor-site morbidity was assessed by questionnaires and specific tests related to anterior knee pain symptoms. RESULTS: Donor-site tenderness was present in 40% patients in the study group and 37.5% patients in the control group (p = 0.59). Pain upon kneeling was present in 33.3% patients in the study group and 37.5% patients in the control group (p = 0.55). Walking in kneeling position elicited pain in 40% patients in the study group and 43.8% in the control group (p = 0.56). The mean visual analogue score for knee pain was 3.0 in the study group and 3.13 in the control group, with no statistically significant difference (p = 0.68). Unlike control group, where a persistent bony depression defect was observed at donor sites, no such defects were observed in the study group. CONCLUSION: Filling the defects of donor sites with HAP:BG blocks do not reduce the anterior knee symptoms in patients with ACL reconstruction using autogenous BPTB graft.

Identification of prolargin expression in articular cartilage and its significance in rheumatoid arthritis pathology.

Qualitative 2D gel-electrophoresis (2DE) protein profiling for osteoarthritis (OA) and rheumatoid arthritis (RA) is challenging because of selective protein loss due to discrepancies in protein precipitation methodologies. Thus, we aimed at developing qualitative protein representation from OA/RA articular cartilage without protein precipitation towards identification of clinically relevant proteins. Chondroitinase digested human articular cartilages from RA patients were subjected to protein extraction using guanidinium hydrochloride (GuHCl) or 8 M urea with 10 or 2% ASB-14-4 or 0.45 M urea with 2% ASB-14-4 with cetylpyridinium chloride (CPC). The GuHCl extract is further protein precipitated with acetone or ammonium acetate-methanol or centricon-fractionated using 100 kDa cut filters and protein precipitated using ethanol. Processed extracts were subjected to 2DE to identify protein profiles. Poor proteins representations were observed in 2D gels with protein precipitated samples compared to qualitative protein representations seen in 2D gels of 0.45 M urea and 2%ASB-14-4 extraction procedure reproducibly. The strategy circumventing protein precipitation generated qualitative 2D gels. RA vs OA gel comparison showed elevated prolargin levels in RA with biglycan levels remaining unaltered. Up regulation of prolargin in RA suggests the likelihood of an adaptive mechanism to control the increased osteoclastogenesis in RA and may have therapeutic value in controlling the disease.

Postoperative Ultrasound Guided Continuous Femoral Nerve Blockade for Unilateral Total Knee Arthroplasty: A Comparison of 0.125% Bupivacaine and 0.2% Ropivacaine.

CONTEXT: Total knee arthroplasty (TKA) is associated with severe postoperative pain which increases morbidity and mortality. AIMS: The aim of the study was to compare the analgesic efficacy and motor blockade of continuous infusion of 0.125% bupivacaine and 0.2% ropivacaine in femoral nerve block following unilateral TKA and to assess the effectiveness of femoral nerve block. SETTINGS AND DESIGN: One hundred and fifty patients undergoing unilateral total knee replacement surgery were included in this prospective observational comparative study. SUBJECTS AND METHODS: Patients are divided into two groups of 75 each. Femoral nerve catheter was placed at the end of surgery using ultrasound. Postoperative analgesia and motor blockade were compared for the next 24 h using visual analog scale (VAS) score, additional analgesic requirement, and Bromage scale. STATISTICAL ANALYSIS: Student's t-test and Chi-square test were applied. RESULTS: There was no statistically significant difference in pain between the two groups though VAS score (during rest and movement) and opioid consumption were lower in bupivacaine group. Nearly 28.6% patients experienced pain and required additional analgesics. Seventy-two percent among them complained of pain in the popliteal region supplied by sciatic nerve. Eight patients excluded from the study also had pain in the popliteal fossa. There was a statistically significant difference in motor blockade between the two groups at 12, 18, and 24 h after starting infusion. Bupivacaine group had a higher percentage of type three blocks compared to ropivacaine group. CONCLUSION: Continuous femoral nerve block (CFNB) with 0.125% bupivacaine infusion provided better analgesia with denser motor blockade compared to 0.2% ropivacaine infusion. CFNB alone is not sufficient to provide adequate analgesia following unilateral TKA.

Solving the Mystery of the Antero Lateral Ligament.

INTRODUCTION: The cruciate ligaments are essential for the antero-posterior stability of the knee joint. In Anterior Cruciate Ligament (ACL) rupture, though reconstructive surgery is a widely accepted and proven procedure, there is still an unacceptably high re-injury rate. The fact that the rotational instability persists even after the surgical reconstruction of ACL injury has evoked a new interest in the study of the soft tissue structures on the anterolateral aspect of the knee joint. The stability of the knee joint was found to improve dramatically if ACL reconstruction is accompanied with the reconstruction of the anterolateral soft structures of the knee. AIM: To identify the attachment and observe the measurable parameters of Antero Lateral Ligament (ALL) and its relationship with the adjacent bony landmarks. MATERIALS AND METHODS: Twenty six cadaveric specimens of knee joints were collected from the Department of Anatomy, Amrita School of Medicine, Amrita Institute of Medical Sciences, Kochi and were dissected for the anterolateral ligament. Various parameters of ALL in extended knee- the length, width at midpoint and at the femoral-tibial attachments and thickness- were measured. The relationship of femoral attachment of ALL with the lateral femoral epicondyle as well as the tibial attachment with the Gerdy's Tubercle (GT) and head of fibula were also noted. RESULTS: ALL was identified in all the 26 cadaveric knee specimens. It was 39.2±7.2 mm in length, 6.5±2.7 mm in width at femoral attachment and 7.4±3.4 mm at tibial attachment, while the thickness was 1.0±0.5 mm. At the femoral attachment it was 7.1±3.4 mm proximal to and 4.0±2.9 mm posterior to the lateral epicondyle while at the distal attachment it was 20.4±3.1 mm posterior to the GT and 21.33±4.6 mm anterior to the head of the fibula. CONCLUSION: The ALL was found to be a distinct, supporting anatomical structure on the anterolateral aspect of the human knee. There is a high incidence of ALL lesions in ACL injuries which causes high-grade pivot-shift. The reconstruction of ALL along with that of ACL could lead to a decrease in the re-injury rates. The anatomical descriptions and the morphometry of ALL may be of great value to the orthopaedic surgeons in performing a more effective reconstructive surgery of ACL.

Tubercular infection after arthroscopic rotator cuff repair.

Tubercular septic arthritis after shoulder arthroscopy has not been reported in the English literature to our knowledge. A case of Tubercular septic arthritis of the shoulder following arthroscopic rotator cuff repair is presented. The sinus and the wound healed well, and laboratory parameters returned to normal, which suggests that the infection was well controlled with the treatment follow-up of 1 year. But the functional score was poor due to repeated surgeries; long-standing infection and the arthritic changes developed. Tubercular infection can occur after arthroscopic shoulder surgery especially in healthcare workers in zones endemic for Tuberculosis. Level of evidence V.

Causes of Total Knee Revision in Emerging Economies: Is It Different from the Western World?

There is limited information in English literature regarding the cause of revision total knee arthroplasty (TKA) in emerging economies. The purpose of this study is to report a detailed analysis of the TKA failure mechanisms from a referral hospital in India and to determine whether the failure mechanisms of primary TKA are different from that of the western world. A total of 53 revision TKAs performed at our institution over the past 5 years were identified. The revision TKA group was divided into subgroups according to the cause of failure, including infection, aseptic loosening, periprosthetic fracture, instability, extensor mechanism failure, and other causes. All revision TKA patients were subdivided into early (less than 2 years from primary) and late (more than 2 years from primary) failure groups depending upon the time interval between primary TKA and revision procedure. The overall common failure mechanisms were infection (73.58%), aseptic loosening (13.2%), and periprosthetic fracture (5.6%). Infection was the most common failure mechanism for early revision (< 2 years from primary) and aseptic loosening was the most common reason for late revision. Our study shows a pattern similar to the earliest trends of revision TKA in western literature reporting infection as the major cause for revision. The level of evidence for the study is Level 3.

Infected shoulder joint with loose Suture Anchor in the joint after Bankart's Repair- A Case Report.

INTRODUCTION: The glenoid labrum is frequently torn in traumatic glenohumeral dislocation; arthroscopic repair is the standard method of treatment. The complications associated with this repair are pulling out of metal suture anchors, chondrolysis and joint infection. The infection of joint after arthroscopy is less than 1%. Staphylococcus is most common organism and rarely followed by Pseudomonas aeruginosa. We report a case of infected shoulder with chondrolysis of the joint and pulled out metal suture anchor lying inside the joint after Bankart's repair. CASE REPORT: A 22-year-old gentleman came to us with complaints of shoulder joint pain & gross restriction of movements for one year, with history of intermittent fever and treatment in nearby hospital. He also gives past history of recurrent dislocation of shoulder with last episode 18 months back, which was diagnosed as Bankart's lesion and arthroscopic Bankart's repair was done 15 months back. He was evaluated at our institute and suspected to have infection of shoulder joint with pulled out metal suture anchor inside the joint. Arthroscopic removal of suture anchor and debridement of shoulder joint was done, Culture was obtained and culture specific antibiotics were given for six weeks, and significant improvement was observed with this line of treatment. At lyear follow up, the patient was able to perform his daily activities with terminal restriction of range of motion. CONCLUSIONS: Shoulder joint infection is rare after Bankart's repair and required a high degree of suspicion. Any foreign materials inside the joint should be taken out & followed with aggressive treatment by debridement, irrigation and culture specific antibiotics. Suppression of joint infection with antibiotics should be avoided specially when there is foreign body inside the joint.

Patient - implant dimension mismatch in total knee arthroplasty: Is it worth worrying? An Indian scenario.

BACKGROUND: The correct sizing of the components in both anteroposterior and mediolateral (ML) dimensions is crucial for the success of a total knee arthroplasty (TKA). The size of the implants selected is based on the intraoperative measurements. The currently used TKA implants available to us are based on morphometric measurements obtained from a Western/Caucasian population. Hence, the risk of component ML mismatch is more common in Asian sub-population, as they are of a smaller built and stature. This study aims to look into the following aspects agnitude of the ML mismatch between the femoral component and the patient's anatomical dimension, evaluation of gender variations in distal femur dimensions, and gender-wise and implant-wise correlation of ML mismatch. MATERIALS AND METHODS: Intraoperatively, the distal femoral dimensions were measured using sterile calipers after removing the osteophytes and compared with the ML dimension of the implant used. ML mismatch length thus obtained is correlated with the various parameters. RESULTS: Males showed larger distal femoral dimensions when compared to females. Males had larger ML mismatch. None of the implants used perfectly matched the patient's anatomical dimensions. Patients with larger mismatch had lower scorings at 2 years postoperative followup. CONCLUSION: Implant manufacturers need to design more options of femoral implants for a better fit in our subset of patients. The exact magnitude of mismatch which can cause functional implications need to be made out. The mismatch being one of the important factors for the success of the surgery, we should focus more on this aspect.

Septic arthritis due to tubercular and Aspergillus co-infection.

Aspergillus septic arthritis is a rare and serious medical and surgical problem. It occurs mainly in immunocompromised patients. Aspergillus fumigatus is the most common causative organism followed by Aspergillus flavus. The most common site affected is knee followed by shoulder, ankle, wrist, hip and sacroiliac joint. Debridement and voriconazole are primary treatment of articular aspergilosis. To the best of our knowledge, there are no reported cases of co-infection of tuberculosis (TB) and Aspergillus infecting joints. We report a case of co-infection of TB and A. flavus of hip and knee of a 60-year-old male, with type 2 diabetes mellitus. He was treated with debridement, intravenous voriconazole, and antitubercular drugs.

Risk Factors of Heterotopic Ossification Following Total Hip Arthroplasty in Patients With Ankylosing Spondylitis.

This study was to identify the risk factors of heterotopic ossification (HO) after total hip arthroplasty (THA) in ankylosing spondylitis. We analyzed 47 hips (24 patients) with ankylosing spondylitis that underwent primary THA. The incidence of HO was 14.9%. The risk factors were divided into modifiable and nonmodifiable factors. Female gender (P=0.008), preoperative ankylosed hip (P<0.001), occurrence of HO in previous surgery (P=0.036) were nonmodifiable risk factors which increased the prevalence of HO. Of the various modifiable risk factors, elevated preoperative ESR (P=0.007), elevated preoperative CRP (P=0.004) and prolonged duration of surgery (P=0.014) were associated with increased occurrence of HO. Perioperative medical intervention to reduce inflammation (ESR and CRP) may help to decrease HO.