How Reliable Is the Cell Count Analysis in the Diagnosis of Prosthetic Joint Infection?

BACKGROUND: Synovial analysis of joint aspirates is a key diagnostic tool; all major diagnostic algorithms include cell count (CC) and polymorphonuclear percentage (PMN%) as important criteria to make the diagnosis. In this context, we conducted this study to analyze the overall accuracy of CC and PMN%. METHODS: A single-center retrospective analysis was performed with clinical data of included patients, with a total of 524 preoperative joint aspirations (255 hips, 269 knees). From the aspirated synovial fluid, we tested the leukocyte esterase activity, leukocyte CC, and PMN%, and sent specimens for aerobic and anaerobic bacterial culture. Depending on the clinical results in accordance with the Musculoskeletal Infection Society criteria for prosthetic joint infection (PJI), 203 patients were then admitted for aseptic revision and 134 patients for septic exchange. RESULTS: In 337 cases (64.3% of the study patients), it was possible to measure the CC. The best cutoff level for PJI of all study patients was 2582 leukocytes/µL (sensitivity [SE] 80.6%, specificity [SP] 85.2%) and a PMN% of 66.1% (SE 80.6%, SP 83.3%). The chosen cutoff levels for PJI of total knee and total hip arthroplasty were 1630 leukocytes/µL (SE 83.6%, SP 82.2%) and a PMN% of 60.5% (SE 80.3%, SP 77.1%) and 3063 leukocytes/µL (SE 78.1%, SP 80.0%) and a PMN% of 66.1% (SE 82.2%, SP 82.4%), respectively. CONCLUSIONS: CC and PMN% are sensitive methods for diagnosing PJI of total hip and total knee arthroplasty. However, there are differences in cutoff levels between knees and hips. International guidelines and diagnostic criteria need revisions in terms of these parameters.

Predictors of iatrogenic lateral wall fractures while treating intertrochanteric fracture femur with the dynamic hip screw system in Indian patients.

BACKGROUND: The integrity of the lateral wall has been reported to be an important factor determining fracture stability in an intertrochanteric fracture. Iatrogenic the lateral wall fracture (ILWF) has been reported while reaming for the lag screw and the barrel of the dynamic hip screw (DHS). This study aimed to identify the predictors of iatrogenic lateral wall fractures (ILWF) while using the DHS, which will help to improve the pre-operative planning and avoid their incidence. MATERIALS AND METHODS: A total of 120 adult patients with intertrochanteric fracture femur treated with the DHS were included in this prospective series. Pre-operatively, the parameters noted were the demographic data, quality of bone using Singh's index, fracture classification using AO/OTA and modified Evan's system. The incidence of ILWF was recorded immediately after the fixation with the DHS. The two groups, i.e. one with ILWF and other without ILWF, were compared. RESULTS: The mean age of 46 females and 74 men in the study was 61 years. Among 120 patients, 87 (72.5 %) patients had a posterior sag that had to be corrected while passing the guide wire and while reaming the neck of femur. The incidence of ILWF was 23.33 %. The incidence of osteoporosis in patients with unstable fracture was 66.67 %. 1.7 % patients with a stable AO/OTA A1 fracture had ILWF, as compared to 50 % of patients with type A2.2 and type A2.3 who sustained an ILWF (p < 0.0001). None of the patients with a 2-part fracture on modified Evan's classification had ILWF, while 53.84 % with a 4-part fracture had ILWF (p < 0.01). CONCLUSION: There is a high risk of ILWF using the DHS in unstable intertrochanteric fractures (AO type A2.2 and A2.3 or 4-part fracture patterns). LEVEL OF EVIDENCE: IV (case series).

Antegrade joint-sparing intramedullary wiring for middle phalanx shaft fractures.

PURPOSE: To evaluate the outcome for surgical stabilization of middle phalanx shaft fractures with joint-sparing antegrade intramedullary K-wire fixation. METHODS: We treated 15 extra-articular transverse or short oblique shaft fractures of the middle phalanx in 13 patients. All fractures were treated with closed reduction internal fixation with antegrade joint-sparing intramedullary K-wires. Patients had a minimum follow-up of 1 year (range, 1-10 y). We assessed the objective outcome at 6 months by calculating total active range of motion. RESULTS: All fractures healed. Based on the total active motion score at 6 months, 10 digits showed excellent results, 3 digits were good, 1 was fair, and 1 was poor. Among 3 patients with an associated flexor tendon injury, 2 had excellent outcomes and one had a poor outcome. For 2 patients with an associated extensor tendon injury, 1 had a good outcome and the other had a fair outcome. CONCLUSIONS: Antegrade intramedullary wiring for extra-articular transverse and short oblique shaft  fracture of middle phalanx is a simple, safe, inexpensive, and joint-sparing technique that provides enough fracture stability, even in cases of associated injuries, for early rehabilitation and functional recovery with the expectation of a good to excellent outcome. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases.

BACKGROUND: Soft tissue defects over the mid- and distal third tibia, heel, dorsum and plantar aspect of the foot and over the medial, lateral and posterior aspect of the ankle are a common scenario in clinical orthopaedic practice. In this article, we describe the utility of the reverse sural fasciocutaneous flap with a cutaneous pedicle in 109 clinical cases with distal lower limb soft tissue defects. MATERIALS AND METHODS: A total of 109 patients were operated on for moderate (5-15 cm) and large (more than 15 cm) soft tissue defects at various sites along the lower limb including foot, heel and sole with the reverse sural fasciocutaneous flap. The defects were secondary to trauma (61 cases), diabetic ulcers (12 cases), post-traumatic scar contracture (8 cases), venous ulcer (4 cases), wound dehiscence (10 cases), leprotic non-healing ulcer (1 case), post-infective wound (1 case), radiation-induced ulcer following radiotherapy for synovial cell sarcoma (1 case), post-fibromatosis excision (1 case), post-dermatofibrosarcoma excision (1 case), post-heel melanoma excision (1 case) and actinomycosis foot (1 case). Patients were assessed for flap uptake and healing of defects. RESULTS: Among the 102 cases analysed, 81 were male and 21 female with an average age of 32.7 years. The average size of the flaps was 148.10 ± 59.54 cm(2). The flap healed uneventfully in 89.21 % of patients. Edge necrosis occurred in 9 cases. Donor site regrafting was required in 7 patients. CONCLUSION: The reverse sural fasciocutaneous flap with a cutaneous pedicle is a quick, versatile, easy and safe soft tissue defect coverage technique to cover most of the soft tissue defects of the lower limb in common orthopaedic practice and does not require any microvascular repair, though it may be cosmetically unappealing in a few cases. LEVEL OF EVIDENCE: IV (Case series).

An Unusual Case of Aneurysmal Bone Cyst of Proximal Phalanx in a 2 Year Old Child.

Aneurysmal bone cysts associated with tubular bones of the hand are rare and even rarer in the paediatric age-group. They are rapidly growing, destructive benign bone tumors. Multiple treatment modalities for aneurysmal bone cyst have been reported in the literature, but controversy exists regarding optimal treatment. We report a case of aneurysmal bone cyst of proximal phalanx of middle finger in a 2 year old child treated at our tertiary care hospital. The diagnosis was confirmed with pre-operative MRI, FNAC and post-operative histopathology. Curettage of the lesion and autologous bone grafting was performed. The hand was immobilized in a short below elbow slab for 4 weeks followed by physiotherapy. Excellent radiological and functional outcomes were obtained with no recurrence at a 5 year of follow up.

Retrospective Analysis of Pain Relief in Total Knee Replacement Surgeries.

BACKGROUND AND AIMS: The aim of the study is to measure the postoperative adequacy of pain relief and functional recovery after unilateral primary total knee arthroplasty or total knee replacement (TKR) with a multimodal approach. SETTINGS AND DESIGN: This was a retrospective observational study done in a tertiary care center. MATERIALS AND METHODS: Eighty patients aged 18-65 years (yrs) with ASA Physical Status Classes I, II, and III operated for unilateral primary TKR surgery under suitable Anaesthesia and was administered ultrasound-guided adductor canal block + periarticular infiltration (PI) from January 2018 to January 2019 were included. Thereafter, the patients visual analog scale (VAS) scores at rest, 45° knee flexion, and mobilization as well as additional analgesia given were noted after going through the records at following time points: 12 hourly for 24 h and thereafter on postoperative day 1 (POD1) and POD2. Level of block, adverse events, and functional recovery (time up and go [TUG] test, 10 s walk test) on POD1 and POD2 were also noted. STATISTICAL ANALYSIS AND RESULTS: The statistical software namely SPSS 18.0 were used for the analysis of the data. The mean VAS score at 12 h was 4.33 ± 1.3 which worsened at 24 h with steady improvement over the next 2 days. Similarly, the case with a mean VAS score at 45° flexion and on mobilization showed a similar trend. At 12 h postadductor block, besides intravenous (i.v.) paracetamol, 32.6% of patients were given tramadol 50 mg i.v. whereas one patient was given a buprenorphine patch in addition to tramadol. The number of patients requiring additional tramadol and buprenorphine patch steadily increased over the next 2 days. The average time taken for the TUG test at 24 h was 30.98 ± 4.77 s, and the average time taken for the 10 s walk test at 24 h was 6.16 ± 1.10 steps with improvement in performance over the next 2 days. CONCLUSION: In our study, our multimodal analgesia model did not provide satisfactory analgesia though mobilization was not hampered.

The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty.

BACKGROUND: Adductor canal block (ACB) is one of the preferred methods of analgesia in total knee arthroplasty (TKA). However, conventionally its use is time-consuming, requires ultrasound guidance, a trained anaesthesia team and adherence to strict asepsis by members of the allied teams. This study was done to assess the feasibility and safety of direct adductor canal block (DACB) as a part of surgeon-administered periarticular infiltration. MATERIALS AND METHODS: Thirty computed tomography (CT) angiography films of the patients were retrospectively reviewed. The trajectory of the needle placement for a DACB in relation to the target region of the adductor block was determined. Fourteen knees in seven cadavers, were dissected through a medial parapatellar approach to perform TKA. After administering the DACB using the technique based on CT data, dissection was carried out to ascertain the correct placement of the dye by visualising the stained areas. RESULTS: The angle of approach in the coronal plane from the entry point to the medial high point and to the adductor hiatus was 10.2° (8-14°) and 6° (3.8-11°), respectively. The angle of approach in the sagittal plane from the entry point to the medial high point and to the adductor hiatus was 7° (5-10.5°) and 29° (19-43°), respectively. In all the 14 cadaveric knees, we confirmed the correct placement of the methylene blue dye as demonstrated by the staining of the adductor canal. CONCLUSION: The study demonstrates the feasibility of the DACB. This surgeon-driven technique is likely to reduce the cost of the procedure, reduce operating room time and also eliminate the risks of surgical-site contamination.

Bisphosphonate associated femoral stress fracture distal to an orthopaedic implant: They are predictable!

Stress fractures are uncommon and often occur in young athletes with high intensity physical activity. These stress fractures occur in weight bearing long bones. Recent literature suggests association of thigh pain, tension side cortical thickening of femoral shaft or a femoral subtrochanteric atypical stress fractures in patients on long term bisphosphonate therapy. The reports of peri-implant bisphosphonate associated atypical stress fractures are very rare. We describe a series of three cases of femoral shaft stress phenomenon around orthopaedic implants who presented with similar prodromal thigh pain and tension side cortical thickening. Two patients sustained fractures as the condition was not recognised despite presenting with prodromal symptoms and one patient with a stress riser who was treated prophylactically. Thus this series aims to highlight the importance of identifying the stress phenomenon around orthopaedic implants, be it intra or extra-medullary implants. The location of these fractures is just distal to the implants and are classically transverse fractures. The treatment of peri-implant stress fractures needs a personalised approach in every case with appropriate choice of implants.

A case of posterior HIP dislocation with intertrochanteric fracture: Beware of the sharp calcar spike.

Posterior dislocation of hip is commonly associated with acetabular lip fractures. Involvement of neck, trochanter or intertrochanteric region is uncommon. Very few cases of posterior hip dislocation with ipsilateral intertrochanteric fracture in the absence of head or acetabular fracture have been reported in the literature. We report such a case in a 19yr male treated with open reduction and internal fixation with sliding hip screw with good functional and radiological outcome at 1 year. Being an extremely rare form of injury, such an injury pattern does not exist in present classification systems. There is a need to revise the existing classification systems and formulate a protocol for the management of the same. Such fractures may also be associated with a sharp calcar spike of the proximal fragment impinging femoral vessels and branches. Attempt at closed reduction without adequate anatomical orientation of the spike can lead to hazardous vascular consequences.

Atypical Osteonecrosis of Humeral Head FollowingAnterior Shoulder Dislocation.

INTRODUCTION: Osteonecrosis of the humeral head is not a very common entity. It is usually associated with comminuted proximal humerus fractures. We report a rare case of osteonecrosis of humeral head after anterior shoulder dislocation without any fracture of the proximal humerus. CASE REPORT: We report a case of a 24-year-old male who sustained a left-sided anterior subcoracoid shoulder dislocation following a road traffic accident. The shoulder was closed reduced, and a post-reduction radiograph was taken to confirm concentric reduction. At 6-month and 2-year follow-up, the radiographs showed sclerotic changes and magnetic resonance imaging (MRI) confirmed the occurrence of osteonecrosis. This is the first such report in contemporary literature. CONCLUSION: Osteonecrosis of the humerus head can occur after an anterior shoulder dislocation. It is important to distinguish between the bone bruise and osteonecrosis. This can be done by serially reviewing the patient's radiographs and MRI.

Giant cell tumor with pathological fracture of C2 with C1-C2 instability: A rare case with review of literature.

Giant cell tumor (GCT) or osteoclastoma is a benign, locally aggressive tumor with a tendency to recur. Involvement of the axial skeleton is very rare and majority of them are seen in the sacrum. The authors report a rare case of a 19-year-old female who presented with a C2 dens GCT with a pathological fracture and atlantoaxial dislocation. The patient was operated in two stages: first stage, with posterior instrumentation and stabilization followed by the second stage, tumor resection by anterior transoral approach. The residual tumor cavity was packed with autologous corticocancellous bone grafts. At a 5-year follow-up, computed tomography scan showed a C1-C2 fusion mass. There was no radiological or clinical evidence of tumor recurrence with the patient having good functional outcome without any neurological deficit.

Giant Cell Tumor of Talus: T-Construct Method of Bone Grafting.

Giant cell tumor (GCT) or osteoclastoma is a benign, locally aggressive tumor with a tendency to recur. Giant cell tumors typically occur in the epiphysis of long bones, including the distal femur and proximal tibia. They are uncommonly found in the small bones of the foot or ankle, and involvement of talus is rare. The authors present a case of GCT of the talar body in a 21-year-old man, which was diagnosed radiologically by the presence of a well-defined osteolytic lesion involving more than half of the talar body with thinning of the cortices. An intralesional curettage and chemical cauterization with phenol was done using a medial approach following an osteotomy of the medial malleolus for adequate exposure. Intraoperative frozen section of curetted tissue was sent and was reported as benign GCT. The residual cavity was packed with autologous corticocancellous bone grafts fashioned in a T-construct like manner. A protective cast was applied for a period of 2 months and patient was subsequently gradually mobilized to full weightbearing status. At 2-year follow-up, there was no clinical or radiologically evident signs of recurrence. There was good consolidation of the bone graft in the talus with no signs of collapse of the weightbearing articular surface. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case Study.

Treatment of atrophic nonunion of middle phalanx in a nine-year-old boy with external distraction and bone grafting.

Nonunion of phalangeal fractures is uncommon and even rarer in the paediatric age group. There is paucity of literature relating to the treatment of atrophic non-union of phalangeal fractures in the paediatric age group. We present a case of five years old atrophic non-union of the middle phalanx of the index finger of the dominant hand in a nine-year-old male child, managed with a staged treatment protocol of initial fracture site distraction with a threaded external fixator followed by delayed bone grafting. This treatment was successful in attaining length and bony union in case of atrophic non-union of the middle phalanx with a good pinch strength and gaining a good range of motion at the proximal interphalangeal joint with little soft tissue dissection.

Salvage of delayed union of a phalangeal fracture with "a hairpin wire".

The advantages of using multiple joint sparing antegrade intramedullary wiring for displaced, transverse and short oblique fractures of the small long bones of the hand has been well documented. This technique provides stable three-point fixation and permits early range of motion exercises to prevent hand stiffness. But in some revision cases where there is a breach or deficiency of subchondral bone due to previous intramedullary wiring or in old neglected juxta articular fractures of the metacarpal, proximal phalanx or middle phalanx with disuse osteopenia, there is a high chance of inadvertent joint penetration with intra medullary wiring, inspite of using blunt tipped bent K wires. This could happen intraoperatively or later in the follow up due to collapse of the fracture ends. We describe an innovative fixation technique which ensures stable fixation, no joint penetration and enables early range of motion to prevent hand stiffness.

Pelvic deformity secondary to tensor fascia lata tightness associated with desmoid tumor.

The iliotibial band is a thick, condensed fascia that, when contracted, leads to a hip flexion, abduction, and external rotation contracture in addition to other joint contractures. Iliotibial band tightness occurs secondary to iliotibial band friction syndrome, which commonly occurs at the lateral femoral epicondylar region. However, a proximal cause of iliotibial band/tensor fascia lata friction syndrome leading to a secondary hip contracture is swelling around the hip; this swelling being a desmoid tumor has not been explicitly described in the literature. The authors present a rare case of a hip contracture in a 28-year-old active man who presented with a functionally disabling hip flexion contracture of 20° with further flexion possible up to 130°, a 45° abduction contracture, and a 20° external rotation contracture with further rotation possible up to 40° with a bony hard swelling in the left gluteal region. Ober's test was positive. Opposite hip and spine examinations were normal. The goals of treatment were to establish the causality between the 2 and to diagnose the etiology of the gluteal mass. Radiographs were normal, with only a pelvic obliquity evident. Magnetic resonance imaging revealed an extra-articular mass abutting the iliac blade. Histopathology confirmed the mass to be a desmoid tumor in the left gluteal region. A wide surgical excision of the mass was performed with negative margins; no postoperative radiotherapy was administered. After rigorous physiotherapy, the hip deformity disappeared at 6 months and there was no evidence of recurrence at 2.5-year follow-up, with the patient able to sit cross-legged and squat.

Fibrodysplasia ossificans progressiva: a case report.

Fibrodysplasia ossificans progressiva or myositis ossificans is a rare disease characterised by bony deposits or the ossification of soft tissues. It transforms skeletal muscles, tendons, ligaments, fascia, and aponeuroses into heterotopic bony deposits through an endochondral process. This leads to progressive immobility; patients are usually wheelchair-bound by the second decade of life and die of thoracic insufficiency by the fourth decade of life. There is no treatment apart from symptomatic treatment with steroids during flare-ups. Excision of heterotopic ossification is not recommended as it can provoke extensive and painful new growths. It is important to detect the disease early from characteristic signs of great toe abnormalities and heterotopic ossifications to improve quality of life through early physiotherapy.

Patients with blunt traumatic spine injuries with neurological deficits presenting to an urban tertiary care centre in mumbai: an epidemiological study.

INTRODUCTION: Traumatic spine injuries are on the rise. The literature is sparse regarding epidemiology of patients with traumatic spine injuries from this part of the world. OBJECTIVES: To analyse the following in patients with traumatic spine injuries with neurological deficits: demographic and social profile, common modes of injury, pre-hospitalisation practices, region of spine affected, severity of neurological deficit and the lay individuals' awareness about traumatic spine injuries. METHODS: The study sample comprised 52 adult patients with traumatic spine injuries with neurological deficits. We collected data on demographic and social characteristics, mode of injury, pre-hospitalisation treatment, interval between injury and presentation, spine region affected and severity of neurological deficits and patient's knowledge about such injuries. RESULTS: The average patient age was 31.32y. The male: female ratio was 2.25:1, and the most common modes of injury were fall from height, followed by traffic accident. More than half of the patients suffered cervical spine injuries, followed by dorsolumbar spine injuries. Only 9.61% of patients received pre-hospitalisation treatment. All patients understood there could be complete functional recovery after treatment for traumatic spine injuries. CONCLUSION: There is a growing need to improve railway and roadway safety equipment and to make it accessible and affordable to the susceptible economically weaker population. Attempts should be made to increase awareness regarding traumatic spine injuries. KEY WORDS: Trauma; Spine; Deficit; Poor; safety; awareness.

Proximal femoral locking plate versus dynamic hip screw for unstable intertrochanteric femoral fractures.

PURPOSE: To compare the outcome in patients who underwent surgery for unstable intertrochanteric femoral fractures using the proximal femoral locking plate versus the dynamic hip screw (DHS). METHODS: 15 men and 5 women aged 32 to 78 (mean, 55) years were randomised to the proximal femoral locking plate group, whereas 14 men and 6 women aged 38 to 75 (mean, 59) years were randomised to the conventional 135-degree DHS group. The time to union, medialisation of the shaft, neck-shaft angle, limb shortening, varus collapse, and functional outcome (using the Hospital for Special Surgery Hip Rating System) were assessed. RESULTS: Respectively in the locking plate and DHS groups, the mean times to union were 14.6 and 16.5 weeks (p=0.067) and the mean limb shortenings were 0.3 and 1.4 cm (p<0.001). Medialisation of the shaft occurred in 0 and 15 patients (p<0.0001); varus collapse occurred in 2 and 5 patients (p=0.408); the functional hip score was good-to-excellent in 18 and 11 patients (p=0.031); deep wound infection occurred in 3 and 2 patients; and implant cut-out occurred in one patient each group. CONCLUSION: A non-collapsing locking plate achieved bone union in unstable intertrochanteric fractures with lower risks of limb shortening and medialisation of the shaft.

Augmented repair of degenerative tears of tendo achilles using peroneus brevis tendon: early results.

UNLABELLED: Reconstruction of degenerated ruptures of the tendoachilles is a challenge. Ruptured tendons and the remaining tendon ends are abnormal. A number of methods have been described in literature reconstruct the tendoachilles, but with variable results(1). We used peroneus brevis tendon in 20 patients to augment the repair of degenerated tendoachilles tears by creating a dynamic loop as described by Teuffer et al(2). All patients were followed up for atleast 18 months. At the last postoperative visit, 18 out of 20 patients were able to do a toe raise. Eighty-five per cent of patients had excellent or good results and 15% had fair or poor results using modified Rupp scoring. Advantages offered by this procedure are the use of a single incision and mini incision and use of a dispensable tendon such as the peroneus brevis without entirely depending on the damaged tendon for healing. KEY WORDS: Degenerative tear of tendoachilles, augmented repair, peroneus brevis tendon.