A study to compare the efficacy of corticosteroid therapy with platelet-rich plasma therapy in recalcitrant plantar fasciitis: a preliminary report.

BACKGROUND: Plantar fasciitis is one of the commonest, and most frustrating, foot ailments seen in a regular orthopaedic clinic. There are a number of modalities available to treat this condition, of which corticosteroid injection is, perhaps, the most popular. However, recent years have seen an increased interest in the use of platelet-rich plasma (PRP) injections in various clinical situations such as plantar fasciitis. METHODS: We undertook a prospective non-randomized study to compare the efficacy of traditional corticosteroid injection (Steroid group) to PRP injection (PRP group), in a cohort of patients. RESULTS: We studied both groups of patients before and after the injections using Visual Analogue Score (VAS), the Foot & Ankle Disability Index (FADI) and American Foot and Ankle Score (AFAS). Our study confirms that there is significant clinical improvement in PRP group at three months after the injection. CONCLUSION: The use of PRP injection can be an attractive alternative in the treatment of disabling, recalcitrant plantar fasciitis. STUDY DESIGN: Cohort study. LEVEL OF CLINICAL EVIDENCE: Level 3.

The natural history of knee osteoarthritis: India-based knee osteoarthritis evaluation (iKare): a study protocol.

METHODOLOGY: Multi-center, cross-sectional, observational study. STUDY CENTER(S): Multiple centers in India. NUMBER OF PARTICIPANTS: 1,000. PRIMARY RESEARCH OBJECTIVE: To characterize patients and treatment utilized for orthopedic patients presenting to both private and public hospital centers in India with knee pain and symptoms suggestive of knee arthritis. INCLUSION CRITERIA: All patients 18 years of age or older who present to a recruiting hospital for treatment of knee pain will be eligible for participation. The subjects must be able to understand and complete the questionnaire. EXCLUSION CRITERIA: Patients with total knee replacement, open wound or evidence of recent surgery, or with a current or a history of tumor and/or fracture in the tibial plateau, femoral condyle or patella, in the affected knee are not eligible. STUDY OUTCOMES: This study aims to characterize the following: general demographics of patients presenting with knee pain, severity of knee symptoms at time of presentation, severity of knee pathology at time of presentation, factors associated with the decision to seek medical care, previous treatments and health care contacts, planned treatment, and gaps in treatment perceived by the patient and treating surgeons.

Silent cardiac comorbidity in arthroplasty patients: an unusual suspect?

We studied 109 patients who were subjected to dobutamine stress echocardiography (DSE) for preoperative cardiac risk assessment before undergoing elective primary hip and knee arthroplasty. Patients were selected for DSE based on several criteria. There were 16 patients with history of ischemic heart disease and 93 patients without. Seven of the 93 patients showed a positive DSE test result, of which 5 developed postoperative cardiac events (P = .00). This study clearly shows that serious "silent" cardiac comorbidity can exist even in so-called healthier patients undergoing routine hip and knee arthroplasty. We believe that identifying these patients and treating them before arthroplasty can significantly improve the overall outcome of the surgery.

Autonomic Denervation Dermatitis: A Relatively Undocumented 'ADD'itional Complication of Total Knee Replacements and Other Surgeries Around the Knee.

BACKGROUND: Infrapatellar branch of the saphenous nerve lies subcutaneously and supplies the anterolateral aspect of knee below the patella. It is extremely susceptible to iatrogenic injuries during the surgeries around the knee, mainly total knee replacements (TKRs). Post operatively the patients present with localised area of numbness and in some instances a traumatic eczematous reaction termed autonomous denervation dermatitis (ADD) is witnessed, leading to skin manifestations that range from a simple rash to extensive lesions. METHODOLOGY: A review of literature was conducted with search of relevant articles from Medline (PubMed), Embase, and Scopus which discussed eczematous skin lesions secondary to total knee replacements. Additionally, we noted studies which described these lesions in other surgeries around the knee like arthroscopies and fracture fixations. RESULTS: Eight studies including atleast one case after TKR were reviewed. There was only one cohort study while the remaining included case reports and small case series. There were 69 cases of ADD appearing after TKR. The appearance of the skin lesions was lateral to the incision in 30/34 operated knees and on both sides of the incision in four knees after TKRs. Bilateral lesions were seen in only six patients of TKRs. There was no functional limitation caused by these lesions and they resolved either spontaneously or after using topical steroids. CONCLUSION: ADD is a relatively uncommonly reported complication of TKRs, which can reduce patient satisfaction and increase surgeon apprehension. Although all cases of nerve damage do not manifest as cutaneous lesions, steps to minimise the damage to the nerve intra operatively should be taken. The diagnosis requires a high index of suspicion, and should not be dispelled as a simple allergic reaction without adequate investigations. Patients should be counselled to alleviate unnecessary fear and apprehensions.

Efficacy of orthobiologic adjuvants to core decompression for hip preservation in avascular necrosis hip.

Head preserving modalities in avascular necrosis (AVN) hip are variably effective in early stages, and further options that could prevent head distortion and osteoarthritis are needed. Core decompression (CD) is the most commonly used surgery in the early stages of osteonecrosis with variable rates of success. The present review aimed to determine the effectiveness of bone marrow aspirate concentrate (BMAC), platelet-rich plasma (PRP), bone morphogenetic proteins (BMP) or their combination with CD in early stages of AVN hip, prior to collapse of femoral head. Additionally, any newer unexplored modalities were also searched for and ascertained. PubMed and SCOPUS databases were searched for relevant articles in English language describing CD with aforementioned orthobiologics. We analysed a total of 20 studies published between 2011 and 2020. There were 6 retrospective and 14 prospective studies. PRP showed improved survival and functional outcomes; however, with only three studies, there is inconclusive evidence for its routine utilization. BMAC enhances the efficacy of CD which can further be increased by culture and expansion of cells or combining it with PRP to stimulate growth. In conclusion, CD with BMAC works more efficiently than CD alone prior to collapse of femoral head in AVN. However, PRP needs more evidence for extensive application. Addition of PRP to BMAC or culturing the latter could further enhance the potency of CD + BMAC combination. Very limited data is available for the efficacy of BMP-7 and the role of intraosseous bisphosphonates should be evaluated for a cheaper and potential alternative.

Arthroscopic view of transient synovitis of the hip joint: a case report.

We present a case of a 13-year-old male patient with hip pain and limp. Inconclusive investigations and persistent symptoms resulted in the patient undergoing hip arthroscopy. At arthroscopy, a large focal cartilaginous defect of the femoral head with synovitis was seen and synovial biopsy confirmed the diagnosis. Arthroscopic debridement of the lesion, synovectomy and non-weight bearing for 6 weeks resulted in relief of symptoms. Transient synovitis is a common diagnosis in young children, but the extent of damage to the femoral head has not been previously described. Transient synovitis may not always respond to symptomatic treatment and hip arthroscopy may be useful in detecting the actual lesion and plan the treatment.

Hip arthroscopy: current concepts and review of literature.

Diagnosis and treatment of intra-articular hip problems in young patients present a challenge to hip surgeons. Previous studies have shown that non-invasive investigations such as radiography, computed tomography and magnetic resonance imaging provide limited help. Non-operative treatment is likely to result in persistent symptoms, and surgical options for intra-articular hip problems involve open arthrotomy of the hip joint, which carries potential risks associated with joint dislocation. Arthroscopy of the hip joint, therefore, seems to be an attractive option. It was once thought that introduction of a straight arthroscope into the ball-and-socket hip joint was almost impossible. Hip arthroscopy has seen several advances since then, and the speed at which it developed in recent years directly corresponded to the rate at which the conditions affecting the hip joint were identified. Athletes and other young individuals with hip injuries are increasingly being diagnosed with an ever evolving series of conditions. Many of these conditions were previously unrecognised and thus left untreated, resulting in premature ends to the patients' competitive careers. Hip arthroscopy, as with any procedure, is not without risks. The procedure is not widely available as it requires specialist equipment and takes a long time to learn. Complications are few, occurring in <5% of patients.

Clinical diagnosis of medial plica syndrome of the knee: a prospective study.

Clinical diagnosis of symptomatic medial plica that causes anteromedial knee pain is poorly defined in the literature; therefore, arthroscopy is considered to be the gold standard for diagnosing this condition. We report our system of clinical diagnosis for medial plica syndrome that is based on patient history and our criteria for clinical examination. This prospective study included 48 symptomatic patients (66 knees) with clinical suspicion of pathological medial plica based on five essential and four desirable criteria. All patients underwent arthroscopic examination to confirm or disprove the clinical diagnosis and also treatment. Arthroscopy confirmed the clinical diagnosis of medial plicae in 44 patients (62 knees) for a diagnostic accuracy of 91.7% (95% confidence interval [CI]: 80% to 97.7%) and sensitivity of 100% (95% CI: 92% to 100%). The 44 patients with pathological medial plicae at arthroscopy were treated by arthroscopic resection. Thirty-nine patients (55 knees) showed satisfactory outcome after arthroscopy (95% CI: 75.4%, 96.2%). Our method of clinical diagnosis of pathological medial plica is simple, inexpensive, noninvasive, and reliable. We conclude arthroscopy is successful in treating this condition.

India-Based Knee Osteoarthritis Evaluation (iKare): A Multi-Centre Cross-Sectional Study on the Management of Knee Pain and Early Osteoarthritis in India.

BACKGROUND: Access to early knee osteoarthritis treatment in low and middle income nations is often believed to be limited. We conducted a cross-sectional study in India to assess prior access to treatment among patients presenting with knee pain to specialist orthopaedic clinics. METHODS: The multi-centre, cross-sectional study included patients presenting with knee pain at 3 hospitals in India. Patients who met the inclusion criteria and provided informed consent completed a questionnaire designed to assess patient demographics, socioeconomic status, knee pain, treatment method, and patient's knowledge on osteoarthritis (OA). Their orthopaedic surgeons also completed a questionnaire on the severity of patient's OA and their recommended treatments. The impact of demographic characteristics on the prescription of treatment options was analyzed using logistic regression. RESULTS: A total of 714 patients met the eligibility criteria and participated in this study. The majority of patients had been experiencing pain for less than 1 year (64.8%) and had previously been prescribed medications (91.6%), supplements (68.6%), and nonpharmacological (81.9%) treatments to manage their knee OA. Current treatment recommendations included oral medications (83.3%), intra-articular injections (29.8%), and surgical intervention (12.7%). Prescription of oral medications was related to younger age, lack of deformities, and lower Kellgren-Lawrence grades (p < 0.01). Patients treated in private hospital settings were more likely to have been previously treated with medications (range, 84.3% to 92.6%; p < 0.01) and physical treatments (range, 61.8% to 84.8%; p < 0.01) than patients treated at government hospitals. CONCLUSIONS: Contrary to the perception, our findings suggest a similar proportion of early knee OA treatment between India and North America.

Patellar instability in Indian population: relevance of tibial tuberosity and trochlear groove distance.

INTRODUCTION: The tibial tuberosity to trochlear groove (TTTG) distance in the western population is extensively studied through various modalities such as X-rays, computerised tomography and magnetic resonance imaging. However, to our knowledge there is very little or no literature support to indicate that TTTG distance has been studied in the Indian population. METHODS: We therefore undertook a study to measure the TTTG distance in 100 MRI scans of normal Indian knees. Patients with the following co-morbidities were excluded from the study; ligamentous laxity, patellofemoral instability, mal-alignment and osteoarthritis. We measured TTTG distance on the axial MRI slices using OsiriX software. RESULTS: The mean value for females was found to be 14.07 mm and that for male was found to be 13.34 mm. Our study indicates that the TTTG distance, using MRI scans as measurement modality, in the Indian population is significantly different when compared to the published western data. DISCUSSION: We believe that this study can form the basis for future studies on the relationship between TTTG distance and patellar instability in Indian population.

Groin pain in athletes: a novel diagnostic approach.

Groin pain in a performing athlete can be very challenging to diagnose and treat. The differential diagnosis includes intra-articular causes, extra-articular causes and non-musculoskeletal causes. A detailed clinical and radiological assessment of groin pain in this group is critical and can identify the underlying pathology. Diagnostic hip block is a valuable tool to differentiate intra-articular causes from extra-articular causes. Hip arthroscopy can help in identifying some of the elusive intra-articular conditions, which were once undiagnosed and therefore, left untreated, resulting in premature ending of competitive careers. This article attempts to explore current thinking on evaluation of groin pain, particularly in young individuals, and to establish a simple protocol for a clinical and diagnostic approach to this difficult problem.

Persistent bilateral anterior hip pain in a young adult due to meralgia paresthetica: a case report.

BACKGROUND: We describe a case report where a young woman presented with persistent bilateral anterior hip pain whose diagnosis was obscure for many months. CASE PRESENTATION: The symptoms started three months after she underwent laparoscopic surgery, with entry portals on both iliac regions of her abdomen. After a thorough clinical examination, a working diagnosis of "Meralgia paresthetica" was made. She responded well to diagnostic block supplemented with local steroids. CONCLUSION: To our knowledge, this is the first ever case report of a bilateral meralgia paresthetica presenting as bilateral persistent anterior hip pain following a laparoscopic procedure.