Is Ultrasound (US)-Guided Platelet-Rich Plasma Injection More Efficacious as a Treatment Modality for Lateral Elbow Tendinopathy Than US-Guided Steroid Injection?: A Prospective Triple-Blinded Study with Midterm Follow-up.

Background: Lateral elbow tendinopathy (LET) has an array of modalities described for its management. The present study analyzed two modalities used for managing the condition. Methods: The present study included 64 non-athletes with LET who failed conservative treatment that included avoiding strenuous activities, ice-fomentation, non-steroidal anti-inflammatory drugs, bracing, and physiotherapy for 6 months. A random allocation of the participants was done, with one group injected with platelet-rich plasma (PRP) and the other group with corticosteroids. The procedure was performed by the same blinded orthopedic surgeon after localizing the pathology using ultrasound. Visual analog scale (VAS) scores, disabilities of the arm, shoulder and hand (DASH) scores, Patient-Rated Tennis Elbow Evaluation (PRTEE) scores, and handgrip strengths were recorded by blinded observers other than the surgeon administering the injection. Results: The average age of the patients was 40 years. The mean VAS score at the latest follow-up of 2 years in the PRP group was 1.25 and it was significantly better than the score of 3.68 in the steroid group (p < 0.001). The mean DASH score at the latest follow-up of 2 years in the PRP group was 4.00 and it was significantly better than the score of 7.43 in the steroid group (p < 0.001). The mean PRTEE score at the latest follow-up of 2 years in the PRP group was 3.96 and it was significantly better than the score of 7.53 in the steroid group (p < 0.001). The scores were better in the steroid group at a short-term follow-up of 3 months (p < 0.05), while they were better in the PRP group at a long-term follow-up of 2 years (p < 0.05). Hand-grip strength was comparable in the PRP group (84.43 kg force) and steroid group (76.71 kg force) at the end of the 2-year follow-up with no statistically significant difference (p = 0.149). Conclusions: Corticosteroid injections alleviated symptoms of LET over short-term follow-up providing quicker symptomatic relief; however, the effect faded off over the long term. PRP injections provided a more gradual but sustained improvement over the long-term follow-up, indicating the biological healing potential of PRP.

Efficacy of Periarticular Local Infiltrative Analgesic Injection on Postoperative Pain Control and Functional Outcome in Sequential Bilateral Total Knee Replacement: A Prospective Controlled Trial in 120 Consecutive Patients.

Background: One of the drawbacks of total knee replacements (TKR) is the early postoperative pain, which affects patient satisfaction and increases the duration of rehabilitation. The present study analyzes the potency of local infiltrative analgesia and its effect on rehabilitation in bilateral sequential TKRs. Materials and Methods: The present prospective observational study was conducted on 120 patients undergoing bilateral sequential TKR performed by a single surgeon using an anterior midline incision with a standard medial parapatellar approach. At the end of the surgery, a periarticular cocktail injection was administered to one knee, whereas the other knee served as the control. Postoperatively, patients were assessed for the pain level in each knee based on the visual analog scale (VAS) score and improvement in the range of motion (ROM). Intergroup and intragroup analyses were performed using the unpaired t test and analysis of variance, respectively. A p value of < 0.05 was considered significant. Results: Of the 120 patients, 58% were women and 42% were men with a mean age of 62.14 ± 8.58 years. The postoperative mean VAS score was significantly lower in the test knee group than in the control knee group (p < 0.05). The postoperative mean ROM was more in the test group as compared to the control group on days 3 and 7 (p < 0.05), whereas it was comparable on day 14 (p > 0.05). Conclusion: Periarticular injection of a drug combination in patients managed with bilateral TKRs that are done simultaneously reduces the early postoperative pain and improves rehabilitation during the first week after surgery.

The Glomus Tumor of Finger - A Case Series.

Introduction: Glomus tumor is a rare hamartoma, common in young female which is excruciatingly painful and affects daily activities. It is usually present in distal phalanx (subungual) but may occur in different locations. A clinician needs high-level suspicion to diagnose this condition. Case Report: We hereby reviewed five cases (four females and one male) of this rare entity selected from patients attending our outpatient department since 2016 and were operated on. Out of these five cases, four were primary cases and one reoccurrence. Each of these was managed with en bloc excision of tumor and confirming it with biopsy after diagnosing it clinically and radiologically. Conclusion: Glomus tumors are rare, benign, and slow-growing tumors that arise from neuromuscular-arterial structures called glomus bodies. Radiologically, magnetic resonance imaging classically shows T1 weight isointense and T2 mild hyperintense. Approaching a subungual glomus tumor through transungual approach with complete excision of the nail plate has reduced the risk of reoccurrence due to complete view/access of the tumor and placing intact the nail plate after excision reduces the incidence of post-operative nail deformity.

Morphometric Analysis of Ulnar Variance and Its Demographic Dynamics Using High Resolution MRI: A Retrospective Study in Indian Population and Review of Literature.

Background: Ulnar variance (UV) is the variation of the level of the distal articulating surface of the radius with respect to the distal articulating surface of the ulna. These variations either positive or negative can predispose to pathologies involving the wrist joint. The aim of this study was to measure the ulnar variance in a subset of Indian population using high-resolution MRI and compare our results with the existing literature. Materials and Methods: Retrospective analysis of 100 normal wrist MRIs were done performed during November 2020 to November 2021 and the ulnar variance was calculated using the Method of Perpendiculars. All the MRI sequences were performed by an experienced radiologist with prior fixed protocol for the study. The measurements were done on the mid-coronal section based on the Method of Perpendiculars using Meddiff Rispacs software. Results: The average age of the participants was 42 years, with Male to female ratio of 0.9:1. 47 MRIs were of the left wrist, while 53 MRIs were of the right wrist. The mean UV was - 0.7 mm (SD-0.175), ranging from - 4.5 mm to 3.5 mm. There was a significant relationship between ulnar-variance and age, as ulnar-variance increases with the age (p value = 0.039). There was no statistically significant correlation of ulnar-variance with gender distribution and handedness. Conclusions: This study utilized high-resolution MRI for measuring ulnar-variance in a subset of Indian population and disclosed that the ulnar-variance affirms a positive correlation with age, while no specific pattern between the ulnar-variance and gender or handedness could be established.

An Analysis of the Structures at Risk from Percutaneous Pinning of Distal Radius Fractures and a Comparison of Two Pinning Techniques: A Cadaveric Study.

Background: A stab incision and blunt dissection prior to wire placement are believed to decrease the risk of injury to underlying structures during percutaneous pinning of distal radius fractures (DRF). However, only a few studies have compared stab incision and blunt dissection to direct wire placement. The aim of this cadaveric study is to analyse the structures at risk during percutaneous pinning of DRF and compare the two methods of wire placement. Methods: A total of 10 cadavers (20 upper limbs) were divided into two groups of five each. Five 2.0 mm Kirschner (K)-wires were inserted into the distal radius under fluoroscopic control in a standard fashion to simulate percutaneous pinning of DRF. In group 1, the K-wires were inserted directly, whereas in group 2, the wires were inserted after making a stab incision and blunt dissection to reach the bone. Each cadaveric limb was then dissected carefully to measure the distance of the K-wires from the branches of the superficial radial nerve (SRN), the cephalic vein and the first dorsal compartment and to determine the structures injured (pierced or in close contact) by the K-wires. Results: Out of the 100 K-wires placed, 18 wires were in close contact or pierced an underlying structure. These included 11 wires injuring tendons, six wires injuring branches of the SRN and one wire injuring the cephalic vein. Direct wire placement (group 1) resulted in injury to eight structures (44.4%) while stab incision and blunt dissection prior to wire placement (group 2) resulted in injury to 10 structures (55.5%). This difference was not statistically significant. Conclusions: Percutaneous pinning of DRF is associated with a high risk of injury to the extensor tendons and branches of the SRN. This risk is not reduced by making a stab incision and blunt dissection prior to K-wire placement.

A case of cervical OPLL and DISH mimicking stroke.

Background: Ossification of the posterior longitudinal ligament (OPLL) is a progressive disorder that mostly involves the cervical spine. It is more prevalent in East Asian countries. Patients typically present with the gradual onset of myelopathy, while about 5% show rapid progression. Case Description: A 51-year-old diabetic and hypertensive male presented with a left-sided hemiparesis following trivial trauma. The first diagnosis was a stroke, but the subsequent workup proved negative. Subsequently, the MRI and CT studies demonstrated significant cord compression due to OPLL extending from C2 to C7. There was also a heterogeneous hyperintense intramedullary cord signal indicative of edema/myelomalacia in the retro- odontoid region. The CT also diagnosed C2-C7 diffuse idiopathic skeletal hyperostosis. Conclusion: Patients with cervical myelopathy due to OPLL rarely present about 5% of the time with the acute onset of neurological deficit following minor trauma. Certainly, one must consider high cervical OPLL as responsible for hemiparesis in a patient whose brain MR has ruled out a stroke.

Short-Term Analysis of the Changes in the Bone Mineral Density of the Proximal Femur After Uncemented Total Hip Arthroplasty: A Prospective Study of 110 Patients.

Introduction Mechanical loading continuously exposes the bone to remodeling processes. Increased load leads to a gain in bone mass, and reduced load results in a loss. After inserting a prosthesis, the proximal femur is bypassed in loading as the bodyweight shifts distally. This lack of load induces bone resorption according to Wolff's law. To avoid this bone resorption, the implant's bending stiffness should be less than the femoral bone. Dual-energy X-ray absorptiometry (DEXA) is a well-accepted method to measure periprosthetic bone mineral density (BMD) after total hip arthroplasty (THA). Since the strength and durability of the fixation of a femoral prosthesis in cementless hip arthroplasty depend largely on the quantity and quality of the surrounding bone, preoperative and postoperative evaluation of the quantity and quality of the femoral bone is very important in the long-term prognosis of hip arthroplasty. Materials and methods A prospective study of 110 patients in the age group of 25-60 years who underwent uncemented total hip arthroplasty in our tertiary healthcare institution was performed. An uncemented, fully hydroxyapatite-coated implant from a single manufacturer was used in all the patients. All the patients were mobilized on the first post-operative day. The BMD was measured at the proximal femur and the distal tip using a DEXA scan. Gruen zones were used for calculating BMD at different anatomical locations in the femur, with particular importance to zones 1, 4, and 7. Results The pre-operative BMD in all zones measured, viz. zones 1, 4, and zone 7 of the affected side, was found to be significantly lower as compared to the BMD values on the control side (P< 0.05). The mean change in the mean BMD was calculated for all the zones and compared with each other using an unpaired t-test. The mean BMD changes were found to be significantly higher in zone 7 in comparison to both zones 1 and 4 (p<0.05). Conclusion Significant periprosthetic bone loss after uncemented THA in the femur was noted in Gruen zones 1, 4, and 7 during the first six months after THA, with the greatest bone loss in the femoral calcar area (zone 7). The lower the preoperative BMD of the patient, the greater the postoperative bone loss.

Are we neglecting long-term effects of vertebral shortening on pulmonary function in spinal tuberculosis?

PURPOSE: In developing part of the world, it is common to see complete destruction of vertebral bodies in tuberculosis. Our study aims to assess the effect of spinal tuberculosis with vertebral shortening on pulmonary function. METHODS: Fifty cases of spinal TB (14 males, 36 females) managed both operatively and non-operatively, who presented to tertiary care institute between years 2011 and 2016 were assessed. Vertebral height loss was assessed by spinal deformity index (SDI). All patients underwent pulmonary function testing using same equipment sitting in upright position. RESULTS: Mean age was 27.9 years (27.9 ± 11.9). 11 patients with mean SDI of 2.7 ± 1.1 showed normal lung function. 36 patients showed restrictive pattern of which 12 were mild, 14 were moderate and 10 showed severe pattern with a mean SDI of 3.8 ± 1.2, 5.6 ± 1.3 and 6.1 ± 1.4, respectively. 3 cases showed obstructive pattern. As the apex of curve shifted proximally, FVC% reduced. Increase in SDI value was associated with a fall in the vital capacity and FEV1. Increase in the kyphotic angle was associated with a deleterious effect on PFT results. CONCLUSIONS: Risk stratification of pulmonary dysfunction resulting from vertebral body height loss due to kyphosis will emphasize the need for early detection of spinal tuberculosis before deformity occurs.

Analysis of Functional Outcomes Following Surgical Management of Neglected Multiple Carpometacarpal Dislocations: A Series of four Cases and Review of Literature.

Introduction: Dislocation of the carpometacarpal (CMC) joint is a rare injury that results following high-velocity trauma. Although there are a few anecdotal reports of isolated CMC joint dislocations, there is scarce literature concerning dislocations involving multiple joints, especially those that are neglected and present late after injury. The injury is often missed when the patient presents to the surgeon since the swelling obscures the characteristic deformity, and the fracture may not be apparent on radiographs. When missed at the initial presentation, they can frequently result in pain, swelling, reduced grip strength, and arthritis. Such injuries require surgical management, along with prompt post-operative physiotherapy to enable the patient to regain satisfactory grip strength and range of motion. Case Report: We retrospectively analyzed four cases of multiple CMC joint dislocations that were managed surgically at our tertiary apex center. The average duration between injury and presentation to our center was five weeks. We used the quick disabilities of the arm, shoulder, and hand (DASH) scores and the maximum handgrip strength to assess the functional outcomes and the visual analog scale (VAS) to assess the pain at regular intervals. All patients showed an improvement in the Quick DASH scores, VAS scores, and the handgrip strength at the latest follow-up. All patients were able to return to their occupation. Conclusion: Early diagnosis and stabilization followed by early mobilization is the key to managing multiple CMC dislocations. The cases that present late are generally associated with contracted soft-tissue structures that prevent the relocation of the injury. Such cases require open reduction, along with a release of the contracted structures and internal fixation. Supervised physiotherapy in the post-operative period is essential to regain a satisfactory range of motion and grip strength.

Is Bilateral Sequential Total Hip Replacement as Safe an Option as Staged Replacement? A Matched Pair Analysis of 108 Cases at a Tertiary Care Centre.

BACKGROUND: Rationale for symptomatic severe bilateral arthritis of the hip is sequential bilateral THR completed under the same anaesthesia. The rarity of procedures and apprehension of complications preclude the widespread use. MATERIALS AND METHODS: Retrospective analysis of prospectively collected data from 108 patients (216 hips) with bilateral arthritis who underwent total hip arthroplasties was done: out of which 54 patients (108 hips) underwent a single-stage sequential procedure (sequential group) and a matched group of 54 patients (108 hips) underwent a two-stage procedure at different admissions (staged group). Patients were matched according to age (± 2 years), gender, American Society of Anaesthesiologists classification, perioperative management protocol and diagnosis. The mean duration of follow-up for sequential group was 5.1 years while that of staged group was 5.3 years. RESULTS: Most patients (88.88%) were operated with uncemented implants having ceramic on ceramic bearing surfaces under spinal or general anaesthesia. The operating time, post-op limb length and functional outcomes of both groups were comparable. Although the total estimated blood loss was significantly less in the sequential group (502 ml) as compared to the staged group (570 ml), the mean blood transfusion requirement was significantly higher (1.6 units) in the sequential group as compared to that in the staged group (0.9 units). The mean cumulative length of hospital stay was significantly longer in the staged group (23 days) compared with the sequential group (16 days). CONCLUSION: Single-stage bilateral total hip arthroplasty is a safe and viable option when performed with expertise in appropriately selected patients without any surge in complications.

Synovitis and synovectomy in haemophilia.

Joint bleeds cause major morbidity in haemophilia patients. The synovial tissue is responsible for removal of blood remnants from the joint cavity. But blood components, especially iron, lead to a series of changes in the synovial tissue: inflammation, proliferation and neovascularization. These changes make the synovium vulnerable to subsequent bleeding and as such a vicious cycle of bleeding-synovitis-bleeding may develop leading to chronic synovitis. The initial step in the treatment is adequate clotting factor supplementation and immediate physiotherapeutic involvement. If these measures fail, synovectomy may be indicated. Non-surgical options are chemical and radioactive synovectomy. This is a relatively non-invasive procedure to do synovectomy, leading to a reduction in pain and joint bleeds. Radioactive synovectomy seems more effective than chemical synovectomy in larger joints. Surgical options are open and arthroscopic synovectomy. Open synovectomy has been found to decrease the incidence of breakthrough bleeds but at the cost of loss of joint motion. Use of arthroscopic synovectomy has been advocated to reduce bleeding episodes with less morbidity to extra-articular tissue and preservation of joint motion. Use of a continuous passive motion (CPM) machine and early mobilization can decrease the postoperative stiffness and promote early recovery. This review addresses the current understanding of synovitis and its treatment options with specific emphasis on chemical and radioactive synovectomy and surgical options.

Anterior Distraction and Reduction with Posterior Stabilization for Basilar Invagination: A Novel Technique.

BACKGROUND: Introduction of a posterior spacer for atlantoaxial joint distraction followed by posterior stabilization is a commonly performed procedure for irreducible atlantoaxial dislocation. We present a unique case in which posterior distraction was associated with increased risk of injury to the vertebral artery (VA) owing to its anomalous course, and hence a novel anterior distraction technique was used. CASE DESCRIPTION: A 45-year-old woman presented with severe neck pain for 1 month with gait imbalance and history of occipital headache for 1 year. Clinical examination revealed upper motor neuron-type findings. Hoffmann sign was positive bilaterally. Clinically, the patient had Nurick grade 4 cervical myelopathy. Magnetic resonance imaging showed basilar invagination along with Arnold-Chiari malformation and syrinx formation at C3-C4 vertebral levels. CT angiography revealed anomalous VAs directly overlying the atlanto-occipital joint. Owing to the anomalous route of the VA and unfavorable slope of facet joints, a 2-step anterior reduction followed by posterior stabilization surgery was planned. We achieved complete reduction using a 10-mm titanium cage inserted via a retropharyngeal approach. Following anterior reduction, instrumented in situ occipitocervical fusion was performed using a plate and screw construct. At 2-year follow-up, the patient is ambulating independently without gait imbalance and with successful radiologic fusion. CONCLUSIONS: The craniovertebral junction has a unique pathoanatomy, and the course of the vertebral artery is variable. Appropriate investigations, including computed tomography angiography, with adequate surgical planning will provide a desirable long-term outcome. Our novel technique has the potential to add a new dimension to the management of irreducible atlantoaxial dislocation.

Association of Thrombophilic Factors in Pathogenesis of Osteonecrosis of Femoral Head in Indian Population.

PURPOSE: Role of heritable blood clotting disorders, both thrombophilias and hypofibrinolysis in causing avascular necrosis (AVN) of femoral head have been studied in regions like Europe and U.S.A. This study was done to investigate the role of heritable thrombophilias in ethnic Indian population. MATERIALS AND METHODS: A case control study of 150 patients (100 cases and 50 age and sex matched controls) of Indian Ethnicity with clinico-radiographically documented idiopathic AVN of femoral head was done after ethics committee approval. DNA was extracted from the blood and PCR analysis was used to study heritable thrombophilic gene mutation (G1691A Factor V Leiden). Enzyme-linked immunosorbent assay (ELISA)-based assays, were utilized to measure antigen levels of protein C, antithrombin III levels and protein S. RESULTS: Nine cases out of 100 showed deficiency of Protein C (9%) while no control showed deficiency of Protein C (p value: 0.028-significant, Odds ratio: 9.791) Ten cases showed deficiency of Protein S (10%) in study population as compared to one case (2%) in control population (p value: 0.038-significant, Odds ratio: 5.44). ATIII deficiency was more prevalent in control group i.e. 22% compared to 11% in study group. Factor V mutation was present in 3% cases as compared to one (2%) in control group. (p value is 0.393-not significant). CONCLUSION: Difference in thrombophilic mutations in various populations indicates possible effect of ethnicity on genetic profile in the development of AVN. This risk stratification will enable in near future early diagnosis and possible role of antithrombotics in disease prevention.

Tuberculosis-The Great Mimicker: A Case of Traumatic Drainage of Cold Abscess.

BACKGROUND: Tuberculosis is characterized by cold abscess, which classically lacks the usual signs and symptoms of inflammation. This case report highlights an atypical presentation of tuberculous cold abscess in the form of appearance of massive swelling in the back overnight after a blunt trauma, mimicking post-traumatic hematoma. CASE DESCRIPTION: A 32-year-old man came to our outpatient department with sudden swelling over the right side of the upper back (25 × 8 × 8 cm) and loin (10 × 4 × 4 cm) after a fall from 1.5 to 2 m height the previous night. The possible differential diagnosis of a traumatic pathology, complicated by a bleeding disorder, resulting in massive hematoma was initially made. However, hematologic investigations were within normal limits. Magnetic resonance imaging suggested an anterior subligamentous abscess at the C7-T1 level tracking through the paraspinal muscles and communicating with the subcutaneous abscess, and at the L3 level, paraspinal abscess tracking to the subcutaneous plane. There was no cord compression or signal changes in the cord. Both the abscesses were pigtailed in antigravity fashion, and material was sent for culture, which proved to be tuberculosis. The patient was treated with antituberculosis treatment for 18 months and improved over the course with complete resolution of symptoms. At 4-year follow-up, the patient is asymptomatic with no evidence of recurrence. CONCLUSIONS: Appearance of massive swelling overnight in patients with cold abscess has not been described in the literature. While evaluating an atypical presentation such as sudden post-traumatic swelling over the thoracolumbar area, the clinician should keep a differential diagnosis of tuberculous abscess and investigate clinicoradiologically to rule out tuberculosis, especially in developing countries.

Learning from Mistakes: Pancreatic Laceration: Devastating Complication During Spine Surgery.

BACKGROUND: Posterior decompression and fusion surgery is one of the most commonly performed surgeries for thoracolumbar tuberculosis with destruction of vertebral bodies. Tuberculosis causes gross destruction of the vertebral bodies and surrounding tissue, making them friable. CASE DESCRIPTION: We present an unusual but dreaded complication which we encountered during posterior decompression and instrumentation surgery in a 65-year-old woman with T10-11 tuberculosis of the spine. During surgical exposure, while reflecting posterior paraspinal muscles on the left side, there was an accidental slip of the Cobb elevator around the transverse process to the extent of two-thirds of its length on the left side anteriorly. The instrument was immediately withdrawn. There was no active bleeding in the field. The rest of the surgery was uneventful. In the postoperative period, however, the patient developed severe abdominal pain with abdominal distention. General surgery opinion was immediately taken and the patient was immediately investigated in the form of a computed tomography scan. It was found that there was a traumatic laceration of the pancreas. The patient underwent emergency exploratory laparotomy and repair of the pancreatic laceration. The patient required intensive monitoring and critical care unit stay and ultimately went on to recover fully over the next few weeks. CONCLUSIONS: This case illustrates the possibility of pancreatic injury should always be kept in mind if the patient develops acute abdominal discomfort in the postoperative period. Also, a multidisciplinary approach along with intensive care backup and vigilant postoperative monitoring is of utmost importance, especially when an unusual event has occurred during the surgery.

Patient satisfaction related outcome after total hip arthroplasty; does bearing surface play a role?

BACKGROUND: The aim of this study was to compare the functional outcome, the patient's perception of the replaced hip joint with different bearing surfaces and to study the effect of femoral head size on joint perception as well. METHODS: One hundred and ten (110) patients, who underwent primary total hip replacement with an average follow-up of 48 months (12-156 months), were assessed for their functional outcome and joint perception. The functional outcome was calculated based on Oxford hip score (OHS) and SF-36. Joint perception was categorized as to whether the replaced joint was perceived like a natural joint or artificial joint with or without restriction of movements. RESULTS: There were 50 patients operated for ceramic on ceramic (CoC-hard-on-hard bearing), 60 patients for hard-on-soft bearing (Metal on Polyethelene-MoP 46, Ceramic on Polyethelene-CoP 14). Most of the patients with hard-on-hard bearings perceived their operated hip like a natural joint (p = 0.04) compared to hard-on-soft bearings. There was no significant difference in the functional outcome (OHS, SF-36) between the two bearing surface groups (p > 0.05). There were fifty patients with 28 mm size head while remaining 60 had larger heads (>32 mm). Patients with large heads felt like natural joint compared to small heads (p = 0.007). CONCLUSION: The hard-on-hard bearing surfaces (CoC) and large femoral heads (32 mm, 36 mm) are perceived more like a natural joint. Different bearing surfaces do not affect the functional outcome after total hip replacement in a medium term follow up.

Bicentric Synchronous Giant cell tumor: A Rare Managed Case Report of Bilateral Fibula Neck Tumor.

INTRODUCTION: Multicentric giant cell tumor (GCT) of bone is an uncommon variant of the typical solitary lesion, with numerous large series reporting an incidence of 0-1.4%. Multifocal lesions also appear to be more locally aggressive than their solitary counterparts and have higher rates of recurrence. Solitary GCT of proximal fibula usually involves fibular head, bicentric synchronous bilateral fibular neck involvement is a rare presentation. CASE PRESENTATION: An otherwise healthy 24-year-old boy presented with a palpable mass in the region of his left proximal fibula and B/L knee pain. He reported pain with activity but no peroneal nerve symptoms. Radiographs of his left knee revealed an expansile lytic lesion at the proximal fibula epimetaphyseal level while the right knee X-ray showed a similar smaller lesion. MRI was done to delineate the accurate extent of the tumor. On the left side, the patient underwent partial fibulectomy (en bloc resection) and chemical cauterization of the edges with 5% phenol. The other side GCT was smaller and the patient was largely asymptomatic, hence was planned for conservative management. CONCLUSION: Multicentric GCT is a known entity and diagnosis should be considered after thorough metabolic workup and after ruling out more common polyostotic skeletal lesions. Selected patients with aggressive (benign) and malignant tumors of the proximal fibula can be treated successfully by resection and with supplementary soft-tissue reconstruction, a good functional outcome can be anticipated.

Viscosupplementation for Management of Knee Osteoarthritis from an Indian Perspective: An Expert Consensus Report.

INTRODUCTION: Knee osteoarthritis (OA) is a progressive degenerative condition and is a significant contributor toward physical disability in the aging population. The current treatment modalities for this condition focus on joint preservation with alleviation of symptoms. Intra-articular hyaluronic acid (IAHA) injections have emerged as the promising mainstay of nonsurgical treatment of OA, especially in patients with mild-to-moderate OA and in certain subgroups of severe OA with comorbidities or with poor response to first-line therapy. The absence of standard guidelines or recommendations for the use of IAHA in India has led to vast variations in the usage of IAHA among practitioners. Hence, this consensus-based document aims to address the issue and establish simplified and easily implemented recommendations on the use of IAHA. METHODS: A group of 78 expert orthopedic surgeons discussed in detail the evidence on appropriate criteria for diagnosis, patient selection, and follow-up evaluation for knee OA at two national meetings. In subsequently held regional meetings, key discussion points and clinical experience-based answers were translated into a questionnaire to develop the final expert consensus-based statements for the use of IAHA in patients with knee OA. RESULTS: Various consensus statements were obtained on the basis of scientific evidence obtained from PubMed, Cochrane-indexed database, and guidelines related to viscosupplementation and knee OA as well as the experts' clinical experience. This document was drafted, reviewed, validated, and modified by the expert panel until a final agreement was reached. CONCLUSION: In this pioneering attempt, the document lays down structured, expert consensus-based statements to guide and align practitioners on the appropriate use of IAHA in the Indian setting. FUNDING: Dr. Reddy's Laboratories Ltd.

Bimalleolar Fracture: A Unique Case of Complication of Complex Regional Pain Syndrome of Lower Extremity After Prolonged Undue Immobilisation.

INTRODUCTION: The complex regional pain syndrome (CRPS) is an agonizing and disabling condition that can affect one or more extremities. Contrary to expectation, sporadic case reports about lower limb CRPS are present in literature. The usual sequence of events with respect to CRPS has always been prior trauma or inciting event, leading to manifestations. We hereby present a case of prolonged and undue immobilization without physical therapy, leading to CRPS in a susceptible phenotype. However, the unique feature of this case was severity of osteoporosis leading to bimalleolar fracture. To the best of our knowledge, there has been no case report of CRPS, leading to fracture. CASE REPORT: A 30-year-old female presented 2 months after trauma to the right ankle due to a fall from a bike. A radiograph of the ankle demonstrated no evidence of any bony injury. As per records, there was no evidence of ligament injury based on magnetic resonance imaging evaluation. As the patient had severe pain and swelling, she underwent conservative treatment in the form of lower limb immobilization in a non-weight-bearing below knee splintage for a period of 8 weeks. After removal of the splintage, the patient continued to have severe pain and swelling and was unable to bear weight. At this point of time, the patient presented to our clinic where follow-up radiographs demonstrated a bimalleolar fracture of the right ankle and diffuse osteoporosis involving talus-calcaneusand metatarsals. After thorough exclusion of other metabolic bone diseases based on various laboratory parameters, the diagnosis of CRPS was made as per Budapest criteria.The case here was diligently managed with multidisciplinary approach. It emphasized on the well-designed rehabilitation of the affected extremity to interrupt the vicious cycle of disuse along with well-controlled analgesia, cognitive psychotherapy, and supervised regular physical therapy. Meticulous medical management included bisphosphonates, careful balance of analgesics including nonsteroidal anti-inflammatory drugs, opioids, and beta-blockers. CONCLUSION: This case report highlights the importance of multimodal stepped care approach in CRPS 1 involving ankle joint. Our report also reiterates the relevance of early mobilization and avoiding undue immobilization.