K2S2O8 promoted metal-free direct C-alkylation of acetophenones with alcohols.

Herein, we report a metal-free synthetic methodology for the C-alkylation of acetophenones following a hydrogen borrowing-like pathway using the commercially available inorganic oxidant K2S2O8 in conjunction with KOtBu. This study articulates the potential of K2S2O8 in fast initiation of the oxidation of benzyl alcohols to develop an atom-economical, easy, and more efficient methodology for the C-alkylation of various acetophenones and synthesis of a variety of substituted quinolines. Experimental data from control experiments, literature and characterization of intermediates through spectroscopic techniques support the proposed plausible mechanism.

Accelerometer-based portable navigation, a faster guide compared to computer-assisted navigation in bilateral total knee arthroplasty-a randomized controlled study.

PURPOSE: There are limited studies in the literature comparing the alignment accuracy of  the large console, imageless, computer-assisted navigation (CAN) and portable, hand-held, accelerometer-based navigation (ABN) in total knee arthroplasty (TKA).  This study was aimed to compare the operative time, blood loss, radiological, clinical and functional outcomes between CAN- and ABN-guided bilateral TKA. METHODS: From Jan 2016 to Dec 2017, 50 patients who underwent bilateral TKA were randomized to undergo either CAN-guided or ABN-guided TKA. Tourniquet time and blood loss were recorded, and intra-op complications were noted. Post-op radiological outcomes at 2 weeks were compared between the groups. The clinical and functional outcomes using the American Knee Society Scores (KSS) and Oxford Knee Score (OKS) were recorded pre-operatively and post-operatively at 3, 6, 12 months and at the end of the study with a minimum follow-up of 48 months. RESULTS: Both groups were well-matched in terms of patient demographic parameters. The mean surgical time per knee was significantly lower in the ABN group (54.5 ± 5.6 min) compared to the CAN group (61.7 ± 13.7 min; p < 0.01). Mean blood loss per knee in the ABN group was 592.1 ± 245.3 mL compared to 682.8 ± 322.0 in the CAN group (p = 0.11). In the ABN group, the mean post-op mechanical axis was 1.2 ± 3.2° (vs 1.5 ± 2.2° in the CAN group, p 0.6), the frontal femoral angle was 88.8 ± 2.3° (vs 88.8 ± 1.8° in the CAN group, p 1.0) and frontal tibial angle was 90.1 ± 1.6° (vs 89.7 ± 1.1° in the CAN group, p 0.14). At 48 month follow-up, the mean functional KSS in the ABN group was 89.0 ± 5.7 (vs 88.1 ± 4.5 in the CAN group, p 0.37) and the mean OKS was 40.5 ± 2.8 (vs 39.6 ± 3.2 in the CAN group, p 0.12). CONCLUSION: Portable, hand-held ABN offers alignment accuracy and functional outcomes in TKA similar to that with CAN, with a reduced duration of surgery. There was no advantage of either of the techniques in terms of clinical or functional outcomes at 48 month follow-up. LEVEL OF EVIDENCE 1.

Total Hip Arthroplasty in Patients With Postpolio Residual Paralysis: A Systematic Review.

BACKGROUND: Patients with postpolio residual paralysis can develop disabling hip arthritis in paralytic as well as a nonparalytic limb, warranting total hip arthroplasty (THA). Limited literature is available on the results of THA among these patients in the form of small series or case reports. We have undertaken a systematic review to evaluate the clinical outcome of THA in patients with poliomyelitis with hip pathologies. METHODS: A systematic search of electronic databases of PubMed, Scopus, and Web of Science pertaining to English literature was undertaken from 1945 to August 2020 to assess the results of THA in patients with poliomyelitis. Information was gathered about demographics, indication, clinical course, complications, functional outcome, survival, and need for any revision surgery in these patients. RESULTS: The literature search revealed 81 articles. Finally, after deduplication and manual selection, 16 relevant articles (128 hips) were included for evaluation. There is a paucity of literature evaluating THA in patients with poliomyelitis over the last 2 decades. The principal reason for arthroplasty was osteoarthritis of the hip in the ipsilateral (paralyzed) limb. A combination of cemented, uncemented, and hybrid implant fixation system was found to be used by surgeons. Addressing instability and perioperative management of limb length discrepancy were found to be challenging propositions. CONCLUSION: THA remains an effective intervention to relieve pain and improve quality of life in patients of poliomyelitis afflicted with either primary or secondary arthritis of the hip. The use of uncemented nonconstrained hip implant designs appears to demonstrate better results than constrained implants.

Total Hip Arthroplasty in Ankylosing Spondylitis With Extension Contracture of Hips.

BACKGROUND: Despite significant pain relief following total hip arthroplasty (THA) in patients with ankylosing spondylitis, a small subset of patients presenting with extra-articular extension contracture of hips remains unsatisfied. METHODS: We retrospectively evaluated the patients with ankylosing spondylitis who underwent simultaneous bilateral THA and had extensor tightness of both hips preoperatively. They were managed with modified Z-plasty of iliotibial band. Patients with windswept deformity, commonly seen in bilateral hip arthritis caused by ankylosing spondylitis, were excluded. RESULTS: Between July 2011 and June 2015, out of 148 patients with bilateral hip involvement, 10 patients (20 hips) had extension contracture of both hips that was addressed during surgery. All patients were followed up for a minimum of 2 years. They could sit comfortably on a chair of height 18 inches with hips and knees flexed to at least 90°. The mean postoperative sum range of motion was 144.6° with an average hip flexion of 95° (range, 90°-105°). None of them had recurrence of extension contracture. There was significant improvement in range of motion and hence ambulation and function. No radiolucent lines exceeding 2 mm were seen in any of the zones around either of the components as evaluated in latest X-rays. CONCLUSION: Extension contracture of hip although rare is a noticeable problem and needs to be addressed during THA. Modified Z-plasty technique of iliotibial band is a reliable method in managing these patients.

Morvan's syndrome-is a pathogen behind the curtain?

Morvan's syndrome is a rare syndrome of likely autoimmune etiology characterized by peripheral nerve hyperexcitability, dysautonomia, insomnia, and fluctuating delirium with prominent hallucinations. Since its first mention in 1890, less than 100 cases have been described in literature. The largest existing review includes details of 29 cases. This case series describes 4 cases (M = 4) of Morvan's syndrome which presented between May and November 2017 to a single tertiary care referral teaching hospital in north India. All the four patients manifested behavioral abnormalities, sleep disturbances, hallucinations, autonomic dysfunction, and clinical signs of peripheral nerve hyperexcitability, mostly as myokymia. Two of the patients had Anti-CASPR2 (contactin-associated protein 2) antibodies. Three of them had electromyography features of peripheral nerve hyperexcitability and only one had elevated cerebrospinal fluid protein level. We hypothesize that Morvan's syndrome and other less characterized autoimmune encephalitis/peripheral nervous system syndromes may have infectious triggers. A possible viral trigger may result in generation of autoantibodies which result in the typical manifestations. We base these hypotheses on the finding of four cases of an orphan disease within a short period of time in a limited geographical distribution.

Staged Reimplantation of a Total Hip Prosthesis After Co-infection with Candida tropicalis and Staphylococcus haemolyticus: A Case Report.

Fungal prosthetic joint infection is a rare complication in total joint arthroplasty. There are no established guidelines for management of these infections. We present a case of a 53-year-old male with a hip joint prosthesis co-infected with Candida tropicalis and Staphylococcus haemolyticus. A two-stage exchange arthroplasty was performed. The patient underwent implant removal, debridement, irrigation with saline solution and application of cement spacer impregnated with vancomycin followed by aggressive antimicrobial treatment in first stage. Complete eradication of infection was demonstrated by negative culture of sonicated cement spacer fluid and negative 16S rRNA and 18S rRNA gene PCR of sonicate fluid, synovial fluid and periprosthetic tissue samples. He underwent second-stage revision hip arthroplasty after 9 months of the first stage. At the latest follow-up, there was no evidence of recurrence of infection. This case illustrates the utility of sonication of biomaterials and molecular techniques for microbiological confirmation of absence of infection in staged surgeries which is required for a successful outcome.

Error Budget for Geolocation of Spectroradiometer Point Observations from an Unmanned Aircraft System.

We investigate footprint geolocation uncertainties of a spectroradiometer mounted on an unmanned aircraft system (UAS). Two microelectromechanical systems-based inertial measurement units (IMUs) and global navigation satellite system (GNSS) receivers were used to determine the footprint location and extent of the spectroradiometer. Errors originating from the on-board GNSS/IMU sensors were propagated through an aerial data georeferencing model, taking into account a range of values for the spectroradiometer field of view (FOV), integration time, UAS flight speed, above ground level (AGL) flying height, and IMU grade. The spectroradiometer under nominal operating conditions (8 ∘ FOV, 10 m AGL height, 0.6 s integration time, and 3 m/s flying speed) resulted in footprint extent of 140 cm across-track and 320 cm along-track, and a geolocation uncertainty of 11 cm. Flying height and orientation measurement accuracy had the largest influence on the geolocation uncertainty, whereas the FOV, integration time, and flying speed had the biggest impact on the size of the footprint. Furthermore, with an increase in flying height, the rate of increase in geolocation uncertainty was found highest for a low-grade IMU. To increase the footprint geolocation accuracy, we recommend reducing flying height while increasing the FOV which compensates the footprint area loss and increases the signal strength. The disadvantage of a lower flying height and a larger FOV is a higher sensitivity of the footprint size to changing distance from the target. To assist in matching the footprint size to uncertainty ratio with an appropriate spatial scale, we list the expected ratio for a range of IMU grades, FOVs and AGL heights.

Evaluation of running knotless barbed suture for capsular closure in primary total knee arthroplasty for osteoarthritis-a prospective randomized study.

AIMS: This study was conducted to compare the barbed vs. traditional suture technique in capsular closure of total knee arthroplasty in terms of closure time, cost, needle prick injury, post-operative complication, blood loss and post-operative function. PATIENTS AND METHODS: Eighty patients in a barbed suture group and 90 in a traditional group were enrolled in this prospective randomized study. RESULTS: Barbed suture was associated with 4.1 minutes (P < 0.001) faster closure. It was found to be cheaper in terms of direct material cost [30.4%]. Needle prick injury was found in 6.7% (P = 0.020) of cases in the traditional group. Blood loss, post-operative complication and post-operative function were comparable in both groups. CONCLUSION: Barbed suture use in capsular closure of knee arthroplasty is an efficient and cost effective method, and recommended for use in the future.

Philadelphia chromosome- positive myelodysplastic syndrome with single lineage dysplasia.

Myelodysplastic syndrome (MDS) is a group of acquired clonal disorders characterized by dysplastic and ineffective hematopoiesis in the bone marrow. Various specific karyotypic and molecular abnormalities associated with MDS further guide the prognosis. Although translocation t(9;22)(q34;q11) (Philadelphia positive [Ph+]) and corresponding BCR-ABL fusion transcript are classically defined to differentiate CML from non-CML myeloproliferative disorders, it is also associated with adult acute lymphoblastic leukemia (Ph+ ALL), acute myeloid Leukemia (Ph+ AML), myelodysplastic syndrome (Ph+ MDS). The occurrence of Ph+ MDS is very uncommon, and a review of literature has shown by far 40 cases so far in which the majority are seen on progression to Leukemia. Few had de novo presence of such chromosomal abnormality. Due to its rarity, this entity has not yet found its space in the current WHO classification. Also, the role of tyrosine kinase inhibitors in such a scenario is still debatable. We found two such cases of de novo Ph+ MDS diagnosed at institute of medical sciences, Banaras Hindu university and a brief literature review.

Alternating Layers of Morselized Allograft and Injectable Ceramic Bone Graft Substitute in Acetabular Reconstruction: A Novel 'Sandwich' Technique.

Background: Impaction of morselized allograft is an appealing procedure for addressing the bone defects. However, concerns remain about its suitability for massive defects. We used a novel "sandwich" technique by impacting the morselized allograft in layers with an intervening layer of injectable bone graft substitute for restoring bone defects during acetabular reconstruction in total hip arthroplasties. Methods: From August 2015 to June 2017, 17 revisions, 4 rerevisions, and 3 complex primary total hip arthroplasties were operated by this novel technique. Postoperatively, serial X-rays were evaluated at regular intervals. Clinical and functional outcomes were assessed by the Harris hip score. To examine if introducing an injectable bone substitute into allograft stock increased its load-bearing capability, simulated mechanical testing using Synbone samples was conducted in the laboratory. Results: The mean Harris hip score significantly improved from 54.6 preoperatively to 86.8 at the latest follow-up. Graft incorporation was seen in all the cases. There was no evidence of component migration or loosening as compared to the X-rays at 3 weeks and 3 months in all the cases. With revision of component as end point, the survivorship was 100% at 82 months. The mechanical testing reported a higher capability of allograft samples when compared to those without bone substitutes. Conclusions: Our data confirms that the use of the "sandwich" technique is a reliable option for major acetabular reconstruction. Early weight bearing is a significant value addition, and short-term results confirm good clinical and functional outcome. Longer follow-up is necessary to assess the status of the construct in the long term.

Clinical outcome in total hip arthroplasty for septic sequelae in childhood : a retrospective study.

AIMS: Adult patients with history of childhood infection pose a surgical challenge for total hip arthroplasty (THA) due to distorted bony anatomy, soft-tissue contractures, risk of reinfection, and relatively younger age. Therefore, the purpose of the present study was to determine clinical outcome, reinfection rate, and complications in patients with septic sequelae after THA. METHODS: A retrospective analysis was conducted of 91 cementless THAs (57 male and 34 female) performed between 2008 and 2017 in patients who had history of hip infection during childhood. Clinical outcome was measured using Harris Hip Score (HHS) and Modified Merle d'Aubigne and Postel (MAP) score, and quality of life (QOL) using 12-Item Short Form Health Survey Questionnaire (SF-12) components: Physical Component Score (PCS) and Mental Component Score (MCS); limb length discrepancy (LLD) and radiological assessment of the prosthesis was performed at the latest follow-up. Reinfection and revision surgery after THA for any reason was documented. RESULTS: There was significant improvement in HHS, Modified Merle d'Aubigne Postel hip score, and QOL index SF 12-PCS and MCS (p < 0.001) and there was no case of reinfection reported during the follow-up. The minimum follow-up for the study was three years with a mean of 6.5 (SD 2.3; 3 to 12). LLD decreased from a mean of 3.3 cm (SD 1) to 0.9 cm (SD 0.8) during follow-up. One patient required revision surgery for femoral component loosening. Kaplan-Meier survival analysis estimated revision-free survivorship of 100% at the end of five years and 96.9% (95% confidence interval 79.8 to 99.6) at the end of ten years. CONCLUSION: We found that cementless THA results in good to excellent functional outcomes in patients with a prior history of childhood infection. There is an exceedingly low rate of risk of reinfection in these patients, even though complications are not uncommon. Cite this article: Bone Jt Open 2022;3(4):314-320.

Outcomes of Total Knee Arthroplasty in Patients with Prior Hardware: A Case-Control Study Using Handheld Navigation.

Presence of hardware in juxta-articular location poses challenge during total knee arthroplasty (TKA). When present in distal femur, it precludes the use of an intramedullary femoral jig during TKA often necessitating removal of hardware leading to prolonged surgery, higher risk of complications, and inferior results. We conducted a case-control study to assess the outcome of TKA among patients with post-traumatic arthritis using a handheld navigation system to perform bone cuts allowing retention of hardware in situ. In 15 patients with post-traumatic arthritis and hardware around the knee (Group A), none or part(s) of hardware were removed while performing TKA. These patients were matched to 15 patients who underwent TKA with handheld navigation for primary OA knee (Group B). The perioperative outcomes assessed were operative time, intraoperative blood loss, length of hospital stay, complications, and 30 days reoperation rate. Clinical outcomes were assessed by using Knee Society Score (KSS) and radiological outcomes using mechanical axis and coronal and sagittal component angles. Mean age of patients at surgery were 65.67 years (Group A) and 66.73 years (Group B). Mean operative time and blood loss were significantly higher in Group A as compared with Group B. At the mean follow-up of 34 months, KSS significantly improved in both the groups. However, there was no statistically significant difference in the clinical and radiological outcomes between the two groups. One patient in Group A developed wound dehiscence and had to undergo debridement and flap coverage within 30 days. The use of navigation helps surgeons in gaining proper limb alignment and implant positioning without complete removal of hardware.

Uneven global and racial representation in major orthopaedic clinical trials: Trends over a decade.

Background: The presence of geographic and demographic disparities in randomized controlled trials (RCTs) may affect the external validity of trials. While some studies have addressed racial or ethnic disparities, they have been limited to a certain region, and there is limited information about the global representation in orthopaedic research. Methods: RCTs published in major medical and orthopaedic journals from 2010 to 2019 were identified. After screening 6961 articles, 1769 trials enrolling 323,506 patients were included. The details of individual trials such as the country of origin, the proportion of women, and the proportion of different racial groups were recorded. Factors associated with reporting and representation of specific demographic groups, and annual changes were assessed. Results: Majority of the trials were from were from United States (US) (N = 380, 21.5%). US (30.7%, N = 99,356), United Kingdom (15.7%, N = 50,691) and Canada (8.3%, N = 26,890) accounted for majority of the enrolled patients. 59.1% of the patients were women. Among US trials reporting race, 81.2% were White, and 9.9% were African American. There was no significant variation in the global distribution (p = 0.056), percentage of women (p = 0.811), or percentage of Whites (p = 0.389) over the years. Conclusion: The top three countries contributed to about 55% of the enrolled patients, whereas they contributed to only 6% of the world population. Overall, women appeared to be adequately represented in the trials, while racial minorities were underrepresented. There has not been any considerable improvement in the representation of developing regions or minorities over the last decade.

Accelerometer-based, hand-held navigation for improved knee alignment in total knee arthroplasty: An observational study.

BACKGROUND: Malalignment in total knee arthroplasty has been associated with poor implant longevity and clinical outcomes. The aim of this study was to investigate the accuracy of accelerometer-based navigation in restoring the mechanical axis. METHODS: 106 primary total knee arthroplasties performed during February 2016 to September 2017 at a tertiary care centre in India were enrolled in this observational study. We noted the intra-op tourniquet time. Two separate blinded observers measured the preoperative mechanical axis and the post operative radiological results (mechanical axis, coronal and sagittal alignment of femoral and tibial components) and the mean value was taken as final data. Interclass correlation was done to look for variability between the two observers. RESULTS: The mean pre operative mechanical axis was 13.74 ± 10.44. The mean tourniquet time was 53.14 ± 7.42 min 91.5% (96/106) knees were within ±3° of neutral mechanical axis with a mean of 1.00° ± 2.68°. The femoral and tibial components with coronal alignment within ±3° perpendicular to the mechanical axis were 93.39% (99/106) and 89.62% (95/106) respectively. In the sagittal plane 89.62% of the femoral components and 87.73% of the tibial components were within ±3° perpendicular to the axis of tibia. CONCLUSION: The Accelerometer based portable navigation system effectively reduces the coronal and sagittal alignment outliers in total knee arthroplasty and has no role in rotational alignment of components.

99mTc-Ethambutol Scan with SPECT/CT in Knee Joint Tuberculosis.

Modalities for in vivo imaging of Mycobacterium tuberculosis are limited and inadequately studied. One such modality is 99mTc-ethambutol scintigraphy which has shown promising results for diagnosis of tuberculosis (TB). Ethambutol, one of the primary antitubercular drugs, is bacteriostatic which acts on the mycolic acid cell wall synthesis of the M. tuberculosis. However, literature on its utility is scarce. The few studies that exist have reported its sensitivity and specificity between 90%- 95% and 71%-85%. We present here a case demonstrating the role of 99mTc-ethambutol scan in knee joint TB.

A New Type of Periprosthetic Fracture: Is It the Time to Update the Unified Classification System?

INTRODUCTION: Increased number of primary and revision arthroplasties performed globally has led to a surge in the numbers of periprosthetic fractures. The Unified Classification System (UCS) advocated a rational approach towards the classification of periprosthetic fractures. We present here an update to the UCS with addition of new fracture pattern encountered in orthopedic practice. METHODS: A retrospective study was conducted to review the service arthroplasty register for the cases with unique fracture pattern where the periprosthetic fracture around total hip arthroplasty was also associated with fracture of the prosthetic component. The details were retrieved from the medical record and the patients were called for a review. The radiological assessment was done with X-rays and clinical assessment with Harris Hip Scores at the latest follow-up. RESULTS: Between 2012 and 2019, 11 patients (7 males and 4 females) were operated for peri-prosthetic fracture with a unique pattern where the fracture of femur was associated with fracture of the femoral stem as well. The mean age of the patient at the time of fracture was 56.8 years (range 42-71 years). All patients were managed with revision hip surgery. One patient died due to malignancy after 7 years of revision surgery. All the surviving patients are doing well with a mean Harris Hip Score of 86.8 at the latest follow-up of 2-9 years (mean 5.0 years). CONCLUSION: With emergence of this new fracture pattern, it is recognition as a separate entity would help in better understanding and augmentation of the existing classification system of periprosthetic fractures.

Is It Worth Delaying Total Knee Replacement as Late as Possible? A Cost-Effectiveness Analysis Using a Markov Model in the Indian Setting.

BACKGROUND: Total knee replacement (TKR) is often delayed in younger patients in an attempt to prolong the longevity of the prosthesis and avoid the risk of revision. But delaying a TKR might compromise the quality of life of young patients who are otherwise active and healthy. METHODS: We built a Markov decision model to study the simulated clinical course of a 50-year-old patient with severe unilateral knee osteoarthritis who could be either treated with conservative therapies or with a TKR at some point in time. An Indian healthcare payer perspective model was used, and lifetime costs (in Indian rupees), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) were calculated. RESULTS: In the base case scenario, patients who did not receive a TKR had a total lifetime cost of ₹216 709 and accumulated 13.59 QALYS in their lifetime. Those who received a TKR without delay (at age 50) accumulated 16.71 QALYS in their lifetime with an ICER of ₹9789 per QALY. When TKR was delayed, the total QALYs decreased, and ICER increased with each year of delay. But the cumulative risk of revision decreased from 27.4% when TKR was performed at 50 years to 10.0% when TKR was done at 70 years. CONCLUSION: Our analysis found that TKR is a cost-effective procedure when the healthcare payer is willing to pay at least ₹9789 ($132) per QALY. The results also suggested that an early TKR is preferred to a delayed TKR despite the higher incidence of revisions.

An algorithmic approach to total hip arthroplasty in patient with post-polio paralysis and fixed pelvic obliquity.

AIMS: Total hip arthroplasty (THA) in patients with post-polio residual paralysis (PPRP) is challenging. Despite relief in pain after THA, pre-existing muscle imbalance and altered gait may cause persistence of difficulty in walking. The associated soft tissue contractures not only imbalances the pelvis, but also poses the risk of dislocation, accelerated polyethylene liner wear, and early loosening. METHODS: In all, ten hips in ten patients with PPRP with fixed pelvic obliquity who underwent THA as per an algorithmic approach in two centres from January 2014 to March 2018 were followed-up for a minimum of two years (2 to 6). All patients required one or more additional soft tissue procedures in a pre-determined sequence to correct the pelvic obliquity. All were invited for the latest clinical and radiological assessment. RESULTS: The mean Harris Hip Score at the latest follow-up was 79.2 (68 to 90). There was significant improvement in the coronal pelvic obliquity from 16.6o (SD 7.9o) to 1.8o (SD 2.4o; p < 0.001). Radiographs of all ten hips showed stable prostheses with no signs of loosening or migration, regardless of whether paralytic or non-paralytic hip was replaced. No complications, including dislocation or infection related to the surgery, were observed in any patient. The subtrochanteric shortening osteotomy done in two patients had united by nine months. CONCLUSION: Simultaneous correction of soft tissue contractures is necessary for obtaining a stable hip with balanced pelvis while treating hip arthritis by THA in patients with PPRP and fixed pelvic obliquity. Cite this article: Bone Jt Open 2021;2(9):696-704.